AG 439 (1) MLINT EAL 41 Midd x The Health af Ealing in the year 1950 EAL 41 The health of Ealing in the year 1950 being the ANNUAL REPORT of the Medical Officer of Health and School Medical Officer WILLIAM G. BOOTH, M.D., B.S., D.P.H., Medical Officer of Health. 3 Mr. Mayor, Aldermen and Councillors of the Borough of Ealing. The presentation of the Annual Report on the health of the Borough of Ealing in the year 1950 affords me an opportunity of reviewing the general position with regard to the health of the citizens and the functioning of the various health services in the Borough. It is particularly appropriate that such a review should be made during this year 1951, which is the Jubilee celebration year of the incorporation of the Borough. I have therefore taken the opportunity of commenting upon a few items from the report of your Medical Officer of Health for the years 1900 to 1902 which covers the period of your attaining the status of a Borough. The matters of most interest at that time were of course the rapid development of the Borough from a housing point of view, the handling of the sewage and water supplies to the quickly developing districts and the incidence of infectious diseases. Taking the three years 1900-1902 and making an average of incidence of the three major mortality diseases among the infectious conditions at that time notifiable, namely, Smallpox, Enteric Fever and Diphtheria, a comparison with the position to-day shows a dramatic change. If one were to compare the population of that time (which was approximately 33,000) with the population of to-day (approximately 190,000) one would have to estimate the incidence of smallpox in the Borough to-day as 25 cases a year with 6 deaths, enteric fever as 70 cases a year with 12 deaths and diphtheria at 240 cases a year with 36 deaths. One would therefore be planning, had there been no change in the situation, for 335 cases of these diseases during the year and a mortality of 54 cases. When I inform you that we have during the past year had no cases of smallpox, no cases of diphtheria, and only four cases of enteric fever in the Borough, with not a single death reported, you will appreciate the great change that has come over infectious diseases as a health problem during your period of Local Government. This result has been achieved by ceaseless vigilance, much educational work on the part of your Health Department, and the keeping abreast of advances in knowledge regarding the control of these diseases. It is a matter on which I think the Borough might well be congratulated, for apart from the tremendous cost involved in the handling of infectious disease on the scale that was faced in the years 1900 to 1902, the amount of human suffering that has been abated is something upon which no price can be placed. Two other matters are deserving of mention in this connection, firstly, the continuous reduction in the infant mortality rate from about 112 per 1,000 at the commencement of the century 4 to 26 per 1,000 for 1950. It was remarked by your Medical Officer of Health at that time, Dr. C. A. Patten, that "your infant mortality rate reflected a sad waste of child life and should be dealt with by improved hygienic surroundings and increased knowledge of infant care and feeding." The reduction to the present figure shows that his words were prophetic and his advice of the best. Secondly, his reference to the need for a crematorium in the year 1900 in Ealing is one which might well be in the forefront of our health programme to-day but for the severe restrictions upon building and development of all kinds. It may well be that even with our present restrictions this is a matter which will have to be given consideration at some time in the not distant future. The transfer of functions to the County Council has left the Borough with most of the matters that were dealt with at the commencement of the Borough's incorporation and it is curious that this turn of the wheel should have put the Borough Medical Services back to a point from where they started. The fundamental nature of housing, sewage, water supplies and infectious disease still remains as firmly as ever the rock upon which preventive medicine is founded. The ancillary services, particularly among those which come under the National Health Service Act, are in the main treatment auxiliaries and are inevitably more and more linked with social services as distinct from preventive health services. In this report an attempt has been made to cover the whole field of health services in the Borough, in order that you may know what is being done in the fields which are no longer under your direct control but which nevertheless play an important part in the services available to the ordinary citizen. Great progress has been made during the year in the development of your Clean Food Campaign and the steady growth of the work is continuing, as it was begun, namely, as an educational function directed at the food handler throughout the whole of the food trade. Visits have been made by a number of bodies to the Borough to see the work that is being done here and although it is only two years since the scheme commenced we have made great strides and are building up on a solid foundation of public knowledge and appreciation of our aims. One of the functions left to the Local Sanitary Authority is that of health education and I am hoping that we shall be able to extend this work in the future. There can be no doubt that by the education of the public we shall achieve our best results. Much still remains to be done and the repercussions of the division of the services by the National Health Service Act are still being felt. 5 It is to be hoped that some amendment of the Act may make it possible for us to co-ordinate health work in our Borough. In the meantime you can look back over the past fifty years with great satisfaction and feel that the efforts made by the Council in the past have borne good fruit in the immediate picture presented by the general maintenance of health in the Borough, as reflected in the pages of this report. Dr. T. Anderson, who was appointed in December, 1947, commenced his duties with you as an Assistant Medical Officer and Resident Medical Officer at Clayponds Hospital. He was appointed as Deputy Medical Officer of Health in succession to Dr. G. Taylor, and resigned from this post in November, 1950. We much regret the loss of his services, as he made a distinct mark in Ealing as a capable and efficient officer. I should like to take this opportunity of expressing my appreciation of the work he did whilst acting as my Deputy. I should also like to express my appreciation of the assistance given me by various members of the staff in the completion of this report, and to all the staff for their excellent work during the year. You have been extremely fortunate to have them. I have the honour to be, Your obedient servant, W. G. BOOTH, Medical Officer of Health. 6 STAFF OF THE PUBLIC HEALTH DEPARTMENT William G. Booth, Medical Officer of Health M.D., B.S., D.P.H. (also Joint Area Medical Officer of Area 7 (Ealing and Acton), Middlesex County Council) Medical Superintendent of the Isolation Hospital (terminated 20/2/50) and the Maternity Hospital (terminated 1/10/50) T. Anderson, Deputy Medical Officer. M.B., CH.B., D.P.H. (Resigned November, 1950). G. T. H. Blackie Chief Sanitary Inspector E. BELFIELD Deputy Chief Sanitary Inspector C. P. H. Meadows Sanitary Inspector (Retired 16/9/50) E. H. Evans J. A. Cummins (Resigned 15/12/50) C. W. Baxter E. W. Budd E. S. Herbert D. J. Huggins A. E. Pooley (Appointed 17/3/50) Harry M. Birrell Chief Administrative Assistant R. S. Leggatt Senior Clerk J. J. Rice Clerk R. Angell „ Miss D. E. McKenzie Shorthand-Typist Mrs. M. G. Byford „ „ Mrs. d. Barker Clerk and Typist R. S. Cox Rodent Operative 7 SOME NOTES ON THE HEALTH OF EALING OVER THE PAST 100 YEARS Ealing in 1851, in its pleasant situation and equable climate, was noted for its health giving qualities, but was still a tiny village, far overshadowed by its growing neighbour, Acton. By this date Acton had grown into a thriving community of 4,700 people. Ealing was still too small to afford the services of a Medical Officer of Health, and this was not to be achieved until 1874. We may compare the Middlesex of 1851 with the Ealing of to-day. Middlesex, outside London, comprised the districts of Staines, Uxbridge, Brentford, Hendon, Barnet and Edmonton, with a total population of 150,606. Ealing's population is now 188,800. Victorian England was flourishing and the birth rate was high— 30 per thousand. The effects of poverty, malnutrition and ignorance however took their toll so that 1 in 7 of the children born died before they reached their first birthday (an infantile mortality rate of 145 per 1,000). The asiatic cholera had reached England 15 years previously and periodic flare-ups still occurred to terrorise the people. Cholera eventually died out in this country some 90 years ago but out of evil came good, for the fear of cholera helped speed long overdue sanitary reforms. In this one year in a population far smaller than present day Ealing, the following number of deaths from certain infectious diseases occurred : Smallpox 64 Measles 65 Diarrhoea 151 Whooping Cough 37 Typhus 109 Cholera 12 Making a total of 438 No death from any of these diseases was recorded in 1950. By 1890 Ealing still remained a village, but one that was growing steadily and now had 27,000 inhabitants. The ladies must have had a "thin time," for the census showed a surplus of 5,000. The public health reports have a curiously up to the minute ring with stories of epidemics of influenza and measles—which last alone led to 38 deaths. 8 Dr. Patten (the Medical Officer of Health of Haling) was very enthusiastic about the new sewerage schemes, "whereas a few years ago complaints regarding sewer emanations were of almost daily occurrence" now the nuisance has been much relieved by the provision of special apparatus to consume the sewer gas and by free and systematic flushing of the main lines of sewers. By 1901 the picture had further changed—Ealing was now a flourishing township of 33,040. Building was proceeding apace— 383 houses were built during the year and another 524 plans had been passed. The main street had been paved with wood blocks and the trams had arrived. "If only the serious noise occasioned by them could be modified, there is little but good to be said of them." TJie sanitary facilities were good and were being expanded rapidly with the growth of the newly formed borough. The horse was still the main means of transport. " With sufficient watering (of the roads) during dry weather, there need be little complaint of the dust nuisance which was such an annoyance and source of danger to health of the occupiers of houses." Diarrhoea was a highly fatal complaint of infants—9 died in that year. It is now certain that dust and flies contaminating the open jugs of milk caused many of these infant deaths. The "new" antitoxin treatment of diphtheria had just been introduced; 6 had died of the 43 cases of diphtheria notified during the year. It is generally agreed that the infantile mortality, i.e., deaths of children under 1 year, gives a very good indication of the health of a community. In 1901, this was 114.4 per thousand, and while the Medical Officer of Health was far from satisfied, yet he had some cause to be proud, by comparison with the rate for England and Wales, which was then 151. 1903-7 was the period when the borough was expanding at a "phenomenal pace"—due to its contiguity to London and " second to no place as regards communications, healthiness and picturesqueness." On July 28th, 1905 a case of smallpox was reported and by the middle of September there was a total of 41 patients in hospital. All recovered but several unvaccinated children had narrow escapes. At this date Dr. Patten was greatly concerned because one-fifth of the population had not been vaccinated. During the same year there was a serious outbreak of typhoid fever, when two persons died out of 13 affected. Several others known to have caught the disease moved out of the Borough during the incubation period. This outbreak was traced to the 9 supply of infected milk. The importance of adequately sterilizing or pasteurising all milk was repeatedly emphasised by the Medical Officer of Health and the long list of diseases which can be transmitted by uncleanly handling was kept well in the public eye. The Brent flooded during the year no less than 20 times— due to the "abnormal rainfall." The sewage farm was swamped and the engines were flooded, thus stopping the workings. Shortly after this a new system of surface drains to cope with storm water was constructed and the plant enlarged by the addition of "sludge presses." By 1905 Pulmonary Tuberculosis had been recognised as a serious menace and the Council had arranged for beds in Mount Vernon hospital to be available for the treatment of certain "poor and eligible persons." "There are more applications than the accommodation affords" had a curiously topical ring. "A notice or placard relative to spitting should be adopted by the Council and placed in suitable places" was emphasised when some ladies attending a function at the Town Hall were subjected to "considerable unpleasantness " ! The outbreak of summer diarrhoea in the hot summer of 1906, helped speed the formation of a Voluntary Association, "The Ealing Ladies' Health Society," which was the precursor of our modern infant welfare clinics. During this year the system of School Health inspections was started in Ealing. The "wonderful change which has taken place in the vehicular traffic in the past 2 years " led to a great increase in the dust nuisance, so much so that an experimental strip of tar macadam road was laid down by the cab rank at Haven Green. By 1910 a School Doctor and Nurse had been appointed, and the provision of a paid Health Visitor was under consideration. The infantile mortality had in four years fallen from 91.2 to 65.2 per 1,000. A consideration of the table below will show some of the vast improvements which have taken place in the last 100 years, viz., a fall in the Infant Mortality from 140 to 26 per 1,000 and a fall in the death rate from 20.3 per 1,000 in 1851 to 9.5 per 1,000 in 1950 (in spite of the greater average age of the population). 1851 1901 1950 Population— Middlesex extra-Metropolitan 150,606 Ealing 33,040 Ealing 188,000 Birth Rate 30 per 1,000 16.2 13.7 Death Rate 20.3 11.1 9.5 Infantile Mortality 145 114.4 26 10 Deaths from certain infectious diseases per 100,000 of population 1851 1901 1950 Smallpox 43 0 0 Scarlatina 13 3 0 Diphtheria 10 18 0 Whooping Cough 25 27 0 Diarrhoea 101 27 5 Measles 73 42 0 Typhus 73 0 0 Enteric Fever Not known 6 0 11 SUMMARY OF STATISTICS Area (in Acres) 8,783 Population (Census, 1931) .. 116,771 Population (estimated middle of 1950) .. 188,800 Rateable Value, 1st April, 1950 £1,877,330 Net Product of a Penny Rate, 1950-51 £7,839 Live Births:— Legitimate Males, 1,280 Females, 1,196 Total 2,476 Illegitimate Males, 65 Females, 49 Total 114 2,590 Birth-Rate per 1,000 of Estimated Population 13.7 Still-Births :— Males, 33 Females, 26 Total 59 Rate per 1,000 total Births (Live and Still-Births) .. 22.3 Deaths : Males, 860 Females, 929 Total 1,789 Death-Rate per 1,000 of Estimated Population 9.5 Deaths of Infants under one year of age:— Legitimate Males, 37 Females, 29 Total 66 Illegitimate Males, 1 Females — Total 1 67 Death Rate of Infants under one year of age:— All Infants per 1,000 Live Births 26 Legitimate Infants per 1,000 Legitimate Live Births 27 Illegitimate Infants per 1,000 Illegitimate Live Births 9 Deaths from Diseases and Accidents of Pregnancy and Childbirth:— From Sepsis — Death-Rate 1,000 Total Births — From other Causes 2 „ „ 0.75 Total 2 „ „ 0.75 Total Deaths Measles — Whooping Cough — Diphtheria — Scarlet Fever — Influenza 6 Tuberculosis of Lungs 48 Other Forms of Tuberculosis 6 Gastro-Enteritis and Diarrhoea 10 12 THE CONTROL OF INFECTIOUS DISEASE Notification is the essential preliminary to control of infectious disease. The diseases notifiable under the Public Health Act 1936 are smallpox, cholera, diphtheria, membranous croup, erysipelas, scarlet fever, typhus, typhoid, enteric and relapsing fever. The Minister of Health has also made regulations whereby the following diseases are also notifiable : plague, poliomyelitis, tuberculosis, puerperal pyrexia, ophthalmia neonatorum, malaria, dysentery, acute primary pneumonia, acute influenzal pneumonia, measles, whooping cough, acute encephalitis and meningococcal infection. Food poisoning is notifiable under the provisions of the Food and Drugs Act of 1938. Isolation. Cases of infectious disease need to be isolated to prevent spread among the general public. The stringency of isolation will depend both on the type of disease and its severity. As a rule the infectivity is most marked for the first few days and then falls off rapidly. Those suffering from infectious disease should not go out into public places, use public transport, mingle with crowds in cinemas, theatres, sports, pass on articles with which they have been in contact, such as library books, or send dirty linen to a public laundry. It is still insufficiently appreciated that the common cold and influenza are highly infectious conditions (although not notifiable), and that sufferers in the early stages have a social duty to isolate themselves at home. The commoner children's complaints such as chickenpox, mumps and German measles are now so mild that hospital treatment is rarely required. Measles and whooping cough may lead to serious complications ; and where the child is very young, debilitated, or unsuitably housed, hospital treatment may be necessary. Scarlet Fever although still prevalent has been of a mild type for many years and in-patient care is not generally advised. The more serious diseases such as diphtheria, poliomyelitis, typhoid, meningococcosis and smallpox are usually nursed in hospital because of the severity of the disease and need for skilled medical and nursing care. Smallpox because of its intense infec- 13 tivity needs to be nursed in special hospitals—away from all other patients. As a rule patients from Ealing are now admitted to Neasden Isolation Hospital, Brentfield Road, Willesden ; Telephone Wil 2117/2118/1850. Exclusion. School children with infectious disease are usually kept out of school for the following periods: Scarlet Fever Seven days after discharge from hospital or home isolation, unless there is a running nose or ear, sore throat or septic spots, in which case this may need to be extended. Diphtheria Depends on the clinical condition, but usually negative throat swabs are advisable before return to school. Measles 14 days from appearance of the rash. German Measles 7 days from appearance of the rash. Whooping Cough 28 days from the appearance of the characteristic whoop. Mumps 14 days from onset or 7 days after disappearance of all swelling. Chickenpox 14 days after appearance of the rash. Home Conditions. When a case of infectious disease is notified the home is visited by the health visitor, or by the sanitary inspector in certain cases, e.g., food poisoning, enteric fever, dysentery, or smallpox. Advice is given as to isolation, disinfection, and home nursing, in order to help prevent spread to others in the household. An attempt is also made to identify the source of infection, that it may be removed where possible. Early diagnosis. Since these diseases are as a rule most infective in the early stages, it is of prime importance that parents should put children to bed as soon as they appear " off colour " and call in their own family practitioner. It is most unwise to take a child with a rash or spasmodic cough to a health clinic or doctor's surgery, where there is high risk of infecting others. The family doctor may in doubtful cases call in a consultant from the isolation hospital—or send specimens for examination to the pathological department of the local hospital. 14 Routes of spread. The infectious diseases are caused by living organisms which pass from one person to another. There are two main routes of transmission depending on the main habitat of germs in the body, i.e., the bowels and the upper respiratory tract (the nose and throat). The diarrhoeal diseases (enteric fever, dysentery, food poisoning and possibly poliomyelitis) are spread by contamination of food from the bowel, either by inadequate hand washing after the toilet, flies, or vermin. The remedy is a higher standard of food hygiene. The respiratory diseases are spread chiefly by droplets sprayed out when blowing the nose. "Coughs and sneezes spread diseases," especially when a handkerchief is not used; and if used, not frequently replaced. Insect borne diseases and water borne diseases are now of comparatively minor importance in this country, thanks to the work of public health and engineering pioneers. Disinfection. When cases of infectious disease are nursed at home it is of great importance to disinfect all crockery, utensils, handkerchiefs and dejecta by boiling, burning or chemicals as may be appropriate. Library books are disinfected where necessary by the Public Health Department. Terminal disinfection of rooms, bedding and blankets is not usually required after the common childhood diseases. A thorough spring clean with generous use of soap and water is now considered adequate. In certain exceptional cases, smallpox, typhoid and tuberculosis, terminal fumigation may still be required and this can be carried out by the staff of the department. 15 The number of cases of infectious disease notified in the Borough in the past twelve years is shown in the following table. Cases of Infectious Disease notified in the Borough. Disease 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 Smallpox — — — — — — — — — — — — Diphtheria 92 33 48 28 13 17 14 29 11 13 16 3 Scarlet Fever 303 116 166 180 448 228 340 232 133 204 176 294 Enteric Fever (including Paratyphoid) 5 4 5 — 1 — — — — 3 8 5 Puerperal Pyrexia 40 30 30 39 41 42 47 35 27 25 27 24 Pneumonia: Primary 50 66 97 105 123 142 110 114 127 189 163 173 Influenzal 26 10 27 17 40 9 14 16 3 6 10 6 Acute Poliomyelitis 1 1 9 2 2 2 3 4 46 10 34 42 Cerebro-Spinal Fever — 7 15 5 1 — 6 6 10 2 14 9 Malaria — 1 1 2 — — — — 1 2 — 4 Dysentery 2 — 3 6 5 24 60 10 5 7 23 24 Erysipelas 37 29 26 36 41 30 26 31 38 32 13 24 Polio-Encephalitis — — — — 1 — — — 6 4 3 — Tuberculosis: Pulmonary 149 156 195 223 233 173 194 275 204 206 205 209 Non-Pulmonary 38 30 28 38 5i 30 23 33 25 27 32 41 Ophthalmia Neonatorum 16 5 2 8 4 3 3 3 5 — 5 3 Total 759 488 653 689 1004 700 840 788 641 730 706 869 The number of cases of infectious disease originally notified sometimes varies due to changes of diagnosis and the following table is therefore given to show the final numbers after correction. Disease Disease Smallpox — Cerebro-Spinal Fever 9 Diphtheria — Malaria 4 Scarlet Fever 286 Dysentery 22 Enteric Fever (including Paratyphoid) 4 Erysipelas 24 Polio-Encephalitis — Puerperal Pyrexia 24 Tuberculosis: Pneumonia: Pulmonary 209 Primary 171 Non-Pulmonary 41 Influenzal 6 Ophthalmia Neonatorum 3 Acute Poliomyelitis 39 — Total 842 16 Cases of Infectious Disease notified during the Year 1950, showing Age Distribution. Disease Total Cases Notified Deaths Ages of Cases Notified. Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to 10 10 to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and over Smallpox — — — — — — — — — — — — — — Diphtheria 3 — — — — — — 1 1 — — — 1 — Scarlet Fever 294 — — 7 16 24 33 175 18 10 8 2 1 — Enteric Fever 5 — 1 1 — 1 — 1 1 — — — — — Puerperal Pyrexia 24 — — — — — — — — 2 18 4 — — Pneumonia: Primary 174 77 14 6 5 10 9 29 8 8 10 17 39 19 Influenzal 7 2 — 1 — — 1 — — — — 1 4 — Acute Poliomyelitis 42 3 — 1 4 1 4 7 7 2 14 1 1 — Cerebro-Spinal Fever 9 2 1 1 1 1 4 — — 1 — — — Malaria 4 — — — — — — 1 — 1 1 1 — — Dysentery 24 — 2 1 3 1 — 3 1 1 5 2 5 — Erysipelas 24 — — — — — — — — — 2 3 12 7 Encephalitis Lethargica — — — — — — — — — — — — — — Tuberculosis: Pulmonary 209 48 — 2 2 3 3 4 4 20 91 30 38 12 N-Pulmonary 41 6 1 — 3 — — 3 4 2 13 10 4 1 Ophthalmia Neonatorum 3 — 3 — — — — — — — — — — — Measles 1016 — 23 107 100 140 135 485 16 1 6 1 2 — Whooping Cough 274 — 18 26 25 29 55 112 3 — 2 2 2 — Totals 2153 138 63 153 159 209 241 825 63 47 171 74 109 39 17 Ages at Death from Notifiable Infectious Diseases. Disease Under One Year 1 to 2 2 to 3 3 to 4 4 to 5 5 to io io to 15 15 to 20 20 to 35 35 to 45 45 to 65 65 and upwards Totals Diphtheria — — — — — — — — — — — — — Scarlet Fever — — — — — — — — — — — — — Enteric Fever — — — — — — — — — — — — — Puerperal Sepsis — — — — — — — — — — — — — Pneumonia: Primary 2 1 — — 2 — — — 4 5 21 42 77 Influenzal — — — — 1 — — — — — 1 — 2 Acute Polio-Myelitis — — — — — — — — 3 — — — 3 Cerebro spinal Fever 2 — — — — — — — — — — — 2 Malaria — — — — — — — — — — — — — Dysentery — — — — — — — — — — — — — Erysipelas — — — — — — — — — — — — — Encephalitis Lethargica — — — — — — — — — — — — — Tuberculosis: Pulmonary — — — — — — — 2 10 9 19 8 48 Non-Pulmonary — 1 — — — 1 — — — 1 3 — 6 Ophthalmia Neonatorum — — — — — — — — — — — — — Measles — — — — — — — — — — — — — Whooping Cough — — — — — — — — — — — — — Totals 4 2 — — 3 1 — 2 17 15 44 50 138 Diphtheria. The high rate of immunisation in the Borough has led to a dramatic fall in the number of cases of diphtheria. During the year only 3 cases were notified as suspected diphtheria (as opposed to 16 in 1949) and none of these were confirmed. When we recall that in 1935, before the start of a mass immunisation campaign, there were 228 cases in Ealing with 15 deaths, we may feel justly proud of these results. There should, however, be no complacency if this happy result is to be maintained, for continuing freedom from the disease depends upon a high level of immunity. The figures for the country as a whole show a similar decline in the number of deaths from 2,480 in 1940 to 85 in 1949. The importance of diphtheria prophylaxis is emphasised to the parents, during the visits to the health centres, by the Health Visitors and the Doctors. This is followed up by "birthday cards" to each child at the age of one year—incorporating reminders of the important points of mothercraft. 18 The personal approach remains the most important method of reaching the public but it is powerfully backed by local and national poster and press campaigns. (Under the provisions of the National Health Service Act, the local Health Authority, i.e., Middlesex County Council, is responsible for ensuring that immunisation facilities are available). During the year, 1834 children were immunised at the infant welfare clinics and 612 by their family practitioners, a total of 2,446. This compares with 2,660 children who reached the age of 1 year in 1950. Of the children born in 1945, By the end of 1946 1,684 had been immunised i.e. 69.2% By the end of 1947 2,085 ,, ,, ,, i.e. 78.4% By the end of 1948 2,217 „ „ „ i.e. 83.4% 1949 (i.e. school entrance age) 2,261 had been immunised i.e. 85% During 1950 in the schools 1,155 "booster doses" were given of which approximately 80% were given to 5—7 years of age group. An attempt has been made to impress upon parents the importance of boosting doses on entering school life and a substantial increase in next year's figures is to be looked for. The combined diphtheria-pertussis antigen is the type most widely used in the Borough. Enteric Fever. Two cases of typhoid fever and 2 cases of paratyphoid were diagnosed during the year. The first case of Typhoid Fever, a girl of 8 years, was diagnosed at Central Middlesex Hospital. Enquiries elicited that a person lodging in the same house was suspected of being a typhoid carrier. Subsequent examination of this person revealed her to be a carrier and undoubtedly the source of infection. No other cases occurred in the house or among the various people associated with the family. The carrier is still being kept under careful surveillance at another address. The second case, a boy of 1½ years, was admitted to Clayponds Hospital on the 11th September, and there diagnosed. On the 4th October the child was removed home by the parents against medical advice, but subsequently cleared up with treatment from his own doctor. Specimens taken from the rest of the family showed his mother to be a carrier and she too is still kept under regular observation. 19 Of the two cases of Paratyphoid the source of infection could not be traced. One was a girl of 6 months who was removed from Carshalton Hospital, where she was being treated for gastroenteritis and pneumonia, to Tooting Hospital, where she was diagnosed as Paratyphoid. The other was a man of forty years whose case history showed nothing likely to point to the source of infection. Carriers. There are two typhoid carriers and one paratyphoid carrier in the Borough. They are kept under careful surveillance and regular laboratory examinations are carried out. The Deputy Medical Officer reviews each case frequently and confers with the patient's medical attendant regarding treatment. Advice is given to the patient or patient's parents and they are reminded of their responsibilities in handling such cases. The use of the newer antibodies such as Chloromycetin has greatly improved the prognosis in cases of enteric fever, but unfortunately has proved of little avail in the treatment of the chronic carrier state. Chloromycetin appears to clear up the disease so quickly that the body does not develop a high level of immunity and carrier states may be produced more frequently than with the natural unmodified disease. This may prove to be a serious public health problem in future years, if the preliminary reports are confirmed. Erysipelas. There was a rise in the number of cases during the year from 12 to 24 but there were no deaths. The average of cases over the past 12 years is 31 per year. The justification for notifying erysipelas is rather slender ; while so many other conditions due to the same organism, the haemolytic streptococcus, are not statutorily notifiable. In the past, deaths from the condition were not uncommon, but no death has now occurred in the Borough for many years. Food Poisoning. Twenty-three people were notified during the year as suffering from food poisoning. In one of these cases the causative agent was identified as Salmonella Typhimurium. This organism is associated with contamination of food by vermin. 20 In another case there was suspicion of the infection being due to a duck egg. It is now well realised that some element of risk attaches to the use of lightly cooked duck eggs. The number of outbreaks of food poisoning in the U.K. has increased very markedly since pre-war days; and moreover, it is probable that only a small proportion of the actual number of cases are notified. This increase is believed to be due to the great increase in communal feeding and the use of prepared foods. The intensive campaign aimed at the food handlers in the Borough is having good results and the standard of food hygiene is showing a distinct improvement. This is referred to in more detail elsewhere in this report. Dysentery. Twenty two persons were notified during the year as suffering from dysentery. In 19 cases the organism was isolated and found to be of the Sonne type. The cases were scattered and isolated and not due to any special focus of infection. Three cases were found at the day nursery mentioned in the 1949 report. An unusual feature is the comparatively large number of adults infected, i.e., 11, but several of these had been in close contact with children. Malaria. Four cases of Malaria were notified, all of which had been contracted abroad. Two were soldiers who had returned from India and China, a third a girl of 19 who had been in Egypt, and the fourth a child of five who had also lived in the East. With the continuing research into the treatment of malaria, it is probable that more efficient drugs will be available shortly, which will cut down the number of relapses. No primary infections of malaria were notified. Measles. Measles remains the commonest of the infectious diseases in childhood. During the year 1,016 cases were notified, 434 less than in the previous year. 21 This is usually a disease of the winter and spring months, but during the month of June a substantial secondary outbreak occurred with 70 cases per week which declined to 7 cases weekly by the middle of September. Measles is usually a very mild disease but it can prove severe in very young or weakly children. It is spread by a filtrable virus borne by droplet spray entering the nose and throat. The intense coughing, sneezing and watering of the eyes in the early stages resembles the common cold, and the sufferer has many opportunities to spread the condition. Children with these symptoms should be isolated, medical care obtained, and the blotchy rash looked for on the fourth day of illness. Temporary protection can be obtained by use of "immune globulins" or "placental extracts" in special cases, such as a very ailing child exposed to severe risk of the disease, but no successful method of long term active immunisation has yet been discovered. Pneumonia. Pneumonia remains far and away the most fatal of the infectious diseases. The number of cases notified has considerably increased in recent years; from 59 in 1935 to 174 in 1950. It is believed that the increase is largely due to more complete returns. In 1935 only the most severe cases were notified, so that there were 63 deaths recorded, 4 more than the number of cases notified. Modern chemotherapy has greatly improved the outlook in this disease. Deaths are now usually found only in the very young or those in the later years of life. Of the 89 deaths in 1949, 4 occurred between the ages of 1—45. In 1935 with only 63 deaths, 13 occurred in this age group. The prognosis in cases of acute primary pneumonia is greatly affected by the general resistance and nutrition of the patient. The improved physique, increased temperance and better health of the present generation should eventually lead to a marked fall in these mortality figures. There were 7 cases of influenzal pneumonia with 2 deaths during the year. 77 Deaths from acute primary pneumonia were reported. 22 Acute Anterior Poliomyelitis and Polioencephalitis. The outbreak of poliomyelitis which commenced in 1947 continues to recur each summer and autumn. The number of cases notified during 1950 in the U.K. was 8,696 which compares with 9,195 in 1947—the worst recorded year. In Ealing the number of notifications received was 42, and of these 39 were confirmed. This compares with 47 confirmed cases in 1947, of whom 6 died. The outbreak commenced in June, and continued steadily with 2 to 4 notifications a week until the end of October, without any very definite peak. Number of Notifications received 42 Number of confirmed cases 39 Paralytic Non-Paralytic Male Female Male Female Under 1 — — — — 1—2 3 2 — — 3—4 1 2 1 1 5—9 4 1 1 — 10—14 2 3 1 1 15—24 — 4 — 1 25 + 3 3 1 4 Total 13 15 4 7 Three deaths occurred during the year—two females and one male. In each case the patient was in the late twenties and appears to have died quickly after the onset of infection. The last case was complicated by the presence of whooping cough which imposed an additional burden. It has recently been shown that the virus of poliomyelitis may be transmitted by faeces and sewage; and the raising of the standard of food hygiene may go some way to help prevent spread in this manner. The public have been asked to co-operate by the avoidance of public halls and unnecessary travel, the restriction of excessive physical exertion and the avoidance of contact with households where illness exists. 23 An understanding of these simple and practical measures may go far to reduce the number of cases. Puerperal Pyrexia. This condition is now defined as any febrile condition occurring in a woman within 21 days of childbirth or miscarriage in which a temperature of 100.4 deg. F. has been sustained for 24 hours or has recurred within that period. Many of these women were suffering from conditions quite unrelated to the confinement. Twenty-four cases of puerperal pyrexia occurred, of whom 15 were in Perivale Maternity Hospital, 3 in other hospitals, 2 in local nursing homes and 4 in the patient's own home. No deaths were reported during the year; this compares with 2 deaths in 1949, 1 in 1948, and 5 in 1935 (the pre-sulphonamide days) when 18 cases were notified—a case mortality of 27.7. Scarlet Fever. The incidence of infectious diseases varies with the season, usually being most prevalent in autumn and winter. Long term changes in the periodicity are also found. Scarlet fever has a long term cycle of 20-30 years, super" •mposed on which there is a short term cycle of 4 to 6 years. With the decline in the incidence there has also been a marked decline in the virulence of the haemolytic streptococcus which is the cause of this disease. At present the disease is manifesting a very mild form. The records show that over the past 200 years there have been several periods in which the disease became mild followed by the recurrence of the more severe form. It has been suggested that the improved general health and nutritional state of the children has produced a greater resistance to the disease. During the year 286 cases of scarlet fever were notified. This represents a moderate increase over 1949 when 175 cases were notified, but only 61 cases were of sufficient severity to require hospital treatment—the same number as last year. The incidence rose markedly during the winter months to 7 cases per week as compared to 3 during the summer. 24 Smallpox. Recent scattered outbreaks of smallpox in various parts of the country have emphasised the serious danger which exists from the importation of this disease. Smallpox is still a common and highly virulent disease in the Far East. The incubation period of 12 days allows ample time for a patient to be infected while abroad—return by air— and not show signs or symptoms until several days after arrival in this country. This chain of events led to the Brighton outbreak in December, 1950, where 10 people died out of 29 confirmed cases. There was no confirmed case of smallpox in Ealing in 1950 but the Public Health Department placed under daily supervision 24 persons who had been at risk. Six people arrived by air from epidemic areas, 2 men were in contact with a case removed from an aircraft at London Airport, and 16 persons arrived by sea in vessels in which a case of smallpox had been diagnosed. All these contacts were successfully vaccinated and remained symptom free. The value of vaccination has been abundantly proved, but for full protection a recent successful vaccination is essential. Vaccination is performed free of charge by the General Practitioners. Primary vaccination in the first year of life is a safe and simple procedure but in 1949 only one-sixth of infants were being vaccinated. Revaccination produces little general upset or complications. It is highly desirable that every infant should be vaccinated not only to produce a high level of group immunity but also to avoid "emergency" primary vaccination in adult life which may be painful and temporarily disabling. Whenever smallpox is introduced into Britain, there is a public demand for vaccination, but this may not protect those unvaccinated persons who first come in contact with the disease. Hospital staff and laundry workers appear to be at special risk and should be revaccinated regularly. Tuberculosis. The number of cases of Tuberculosis notified during the year is set out in the following table in which the cases are classified into the type of disease, age and sex groups. Notifications are received from general medical practitioners and superintendents of sanatoria. Occasionally the first intimation is a death certificate. The number of cases notified remained very constant over the past 3 years. 25 The number of deaths from Pulmonary Tuberculosis fell from 70 in 1949 to 48 in 1950. This corresponds with the great improvement for the U.K. as a whole, where the rate fell from 40 to 32 per 100,000—a new record. It will be seen from the graph that whereas the notification rate of pulmonary tuberculosis in Ealing since 1935 has remained fairly constant (apart from the rise during the war years) there has been a steady decline in the mortality from 66 in 1934 to 25 in 1950. An interesting feature shown by the tables is that in men the risk appears to increase with age, whereas in women the older age groups appear less susceptible. This is apparently related to the mode of infection. The cases in young women are due to primary infections in adult life ; the cases in elderly men are due to re-infection or breakdown of resistance in a previously healed disease process. It is most important to prevent the young non-immune person receiving a large dose of virulent tubercle bacilli. Young women at special risk, such as nurses, are now tested as a routine and all those who are negative reactors are immunised with B.C.G. vaccine. An experimental scheme was started by Dr. P. Dick to test and immunise the children of school leaving age in certain parts of the borough. Although the death rate is falling, the number of notifications remains high. This is in part due to more complete diagnosis of the milder cases by means of the mass radiography system. The long delay in the admission of patients to sanatoria undoubtedly is a potent factor in the continued spread of the disease. Pressure on beds also leads to too early discharge of patients from hospital before the disease is fully healed. The outlook recently for cases of tuberculosis has been dramatically improved by the use of several new drugs (Streptomycin, P.A.S. Theosemicarbazone) and the great advances in the technique of chest surgery. Tuberculous meningitis was once a uniformly fatal disease but now a substantial number of affected children recover. The main line of prevention remains the raising of resistance by good housing, adequate ventilation and a mixed and nutritious diet. A better standard of social hygiene, such as avoiding of promiscuous coughing and sneezing, helps check the spread of respiratory disease. 26 27 Certain occupations have been shown to carry a high risk of this disease and great efforts have been made to improve working conditions (suppression of dust, regular X-rays) to lessen the risks. The patient with tuberculosis must be considered in relation to his family. Adequate accommodation is essential if the risk of infection to other members of the family is to be avoided. The Council has made provision for a certain degree of priority in rehousing on health grounds. The capacity for arduous work is much diminished in the patient with healed disease, so that a sedentary non-competitive occupation with good conditions is essential. Various schemes have been started recently for special workshops and an interesting experiment has been undertaken along these lines in another area of Middlesex. Age Periods New Cases Deaths Pulmonary Non-Pulm'y Pulmonary Non-Pulm'y Male F'male Male F'male Male F'male Male F'male 0—1 — — 1 — — — — — 1—5 7 3 2 1 — — — — 5—10 3 2 — 3 — — — — 10—15 3 1 2 3 — — 1 — 15—20 10 13 2 1 — 1 — — 20—25 12 23 2 1 2 — — 1 25—35 25 28 2 6 5 3 1 — 35—45 12 20 4 6 6 4 — — 45—55 16 5 1 1 6 5 — 1 55—65 14 1 2 9 1 1 1 65 upwards 7 4 1 — 3 3 — — Total 109 100 19 22 31 17 3 3 The number of new cases of Pulmonary Tuberculosis notified was 209 compared with 205 in the previous year, while the number of cases of Non-Pulmonary Tuberculosis was 41 compared with 32 in the previous year. There was a total of 54 deaths (48 Pulmonary, 6 Non-Pulmonary) compared with 70 Pulmonary, 6 Non-Pulmonary in the previous year. Whooping Cough. The relative importance of whooping cough as a cause of death in infancy has greatly increased with the disappearance of diphtheria as a serious menace to infant life. Whooping Cough not only kills but severely debilitates the children with repeated coughing and vomiting. 28 Serious sequelae such as partial collapse of the lung, emphysema and the reactivation of healed foci of tuberculosis are not uncommon. During the year, once again, no deaths from whooping cough were reported and this compares with an average of 2.5 deaths each year in the preceding decade. The number of cases recorded fell by 29 to 274 and this is only the fourth time in the past twelve years that this figure has fallen below 300. A new and improved American type of vaccine has recently been introduced for prevention of the disease and it is expected that this will produce a steady fall in the number of cases in future years. Deaths Cases 1939 1 520 1940 2 186 1941 3 638 1942 5 331 1943 4 450 1944 2 380 1945 1 236 1946 2 271 1947 3 310 1948 2 383 1949 — 303 1950 — 274 29 Causes of Death, 1950. Cause of Death Deaths, 1950 Total Deaths 1949 Male Female Total Tuberculosis, Respiratory 31 17 48 70 Tuberculosis, Other 3 3 6 6 Syphilitic Disease 6 — 6 11 Diphtheria — — — — Whooping Cough — — — — Meningococcal Infections 1 1 2 — Acute Poliomyelitis 1 2 3 1 Measles — — — — Other Infective and Parasitic Diseases 3 1 4 * Malignant Neoplasm, Stomach 26 21 47 56 ,, ,, Lung, Bronchus 55 14 69 * ,, Breast ... 1 38 39 36 ,, ,, Uterus ... — 23 23 20 Other Malignant Lymphatic Neoplasms 87 104 191 225 Leukaemia, Aleukaemia 4 2 6 * Diabetes 2 7 9 12 Vascular Lesions of Nervous System 83 133 216 206 Coronary Disease, Angina 125 79 204 562 Hypertension with Heart Disease 37 34 71 Other Heart Disease 113 186 299 Other Circulatory Disease 21 49 70 88 Influenza 5 1 6 13 Pneumonia 46 33 79 91 Bronchitis 47 33 80 107 Other Diseases of Respiratory System 7 3 10 30 Ulcer of Stomach and Duodenum 14 7 21 24 Gastritis, Enteritis and Diarrhoea 2 8 10 7 Nephritis and Nephrosis 16 10 26 36 Hyperplasia of Prostate 17 — 17 * Pregnancy, Childbirth, Abortion — 2 2 3 Congenital Malformations 10 7 17 * Other Defined and Ill-Defined Diseases 69 82 151 126 Motor Vehicle Accidents 14 6 20 21 All other Accidents 10 19 29 * Suicide ... 3 4 7 11 Homicide and Operations of War 1 — 1 * Total 860 929 1,789 *Not given in 1949 (Revised classification). Total Deaths in 1949 1,872 MASSAGE AND SPECIAL TREATMENT ESTABLISHMENTS During 1950 five new licences were granted, making a total of 24 licensed establishments for massage and special treatment in the Borough. In addition to these, there were four establishments granted exemption from licensing by virtue of being conducted either by medical practitioners or by members of the Chartered Society of Physiotherapists. 30 Since 1943 the Council has made it a condition of registration that the applicant's name should be on the Register of the Board of Registration of Medical Auxiliaries which admits only those persons who have trained with a qualifying body recognised by the Board. In September an applicant for a chiropody licence appealed to the Petty Sessions against the Council's refusal to grant a licence. The case was heard by the Ealing Magistrates in October and the Council were directed to grant a licence, subject to the condition that the treatment given should be confined to the treatment of malformed nails and superficial excrescenses occurring on the feet (such as corns, warts and callosities) and bunions, except when acting under the direction and supervision of a medical practitioner. After this case the Public Health Committee made the following recommendations : That in future licences would be granted only to (1) (а) Chiropodists whose names are included on the Register of the Board of Registered Medical Auxiliaries, or (b) Chiropodists possessing equivalent technical qualifications, subject to the condition that they comply with the same code of ethics. (2) That before refusing a licence to a chiropodist he be given an opportunity to appear before them to show cause why the Committee should not refuse to license him. Of the four new licences, two were granted under the revised conditions. Four applicants were refused licences on the grounds of being insufficiently qualified. Apart from Leyton which has a byelaw, Ealing probably enjoys the privilege of being the most difficult area in the country for an unqualified masseur or chiropodist to obtain a footing for a practice. NURSING HOMES. In November, 1949, a letter was received from the Ministry of Health requesting the Council's observations upon the proposal of the Middlesex County Council that the delegation to the Borough Council of their powers regarding the registration of Nursing Homes should be withdrawn. The powers of registering nursing homes remained with the Borough Council at that time, but the Middlesex County Council had been carrying out these functions since the 5th July, 1948. 31 The Public Health Committee recommended that the Minister of Health should be informed that in view of the advantages of local administration in this matter the Borough Council considered that they should continue to exercise the functions relating to nursing homes under Part VI of the Public Health Act, 1936. The supervision of Nursing Homes in the Borough was consequently resumed by the Public Health Department. Number of Nursing Homes on Register at beginning of year 16 Number of Homes discontinued during the year 1 Number of Homes closed by Order made under Section 188(1) of the Public Health Act, 1936 1 Number of Homes remaining on the Register at the end of the year 14 Following the death of a patient in a Nursing Home about which there had been many previous complaints, the Public Health Committee recommended that the Town Clerk should give the owner 14 days' notice of the intention of the Council to cancel the registration. The owner together with her legal representative attended a special meeting of the Public Health Committee. After careful consideration of all the facts the Committee resolved that an order should be made under Section 188 (1) of the Public Health Act, 1936, cancelling the registration on the following grounds : (a) That for reasons connected with staffing the home was not fit to be used as a nursing home. (b) That the home was not under the charge of a person who was either a registered medical practitioner or a qualified nurse or was resident in the home. (c) That there was not a proper proportion of qualified nurses employed in the nursing of the patients in the home. The owner appealed against this decision, but the Court upheld the Council's order, and the nursing home was closed. This building was subsequently purchased by the King Edward Hospital Fund and is likely to be used as a "halfway house" for the elderly infirm who are neither hospital nor welfare cases. This group of the population is probably the biggest problem facing the social workers of to-day. On all sides one has complaints of the inadequacy of the present arrangements by which the elderly can only be dealt with on the basis of acute sickness or full health and the opening of this home by the King Edward Hospital Fund is an excellent move in the right direction. All nursing homes in the Borough are inspected at least twice a year. 32 MEDICAL EXAMINATIONS. Candidates for permanent appointment to the Council's service are required to pass a medical examination on appointment as are manual staff for. admission to the Sickness Pay scheme of the National Joint Industrial Council for Local Authorities NonTrading Services. During the year the following examinations were carried out Administrative, Technical and Clerical Staff 44 Manual Staff 4 Sickness Pay Scheme 127 Total 175 SANITARY CIRCUMSTANCES OF THE BOROUGH Water. 1. There are three sources of supply in the Borough. The Greenford North, Greenford South, and Perivale Wards are supplied by the Rickmansworth and Uxbridge Valley Water Company, with the exception of five roads in Perivale Ward, which are served by the Colne Valley Water Company. The remainder of the Borough is supplied by the Metropolitan Water Board. The water supply from these sources has been satisfactory both in quantity and quality. 2. No samples were taken by my Department from any public supply either for bacteriological or chemical analysis. 3. No plumbo-solvent action occurs in any of the water supplies. 4. No action was taken in respect of any form of contamination. 5. Water from public mains is supplied to 49,831 houses with an estimated population of 188,800. There are eight factories in the Borough using water from deep borings ranging in depth from 300 feet to 600 feet. The water is used for general factory purposes and in four of them it is also used for drinking. The analyses of seven samples taken from these wells showed that the supplies were wholesome in character and suitable for drinking and domestic purposes. Rivers and Streams. No complaints were received during the year regarding the River Brent or its tributary streams. 33 Further samples were taken from a stream in the North Greenford area which was the subject of complaints in 1949 and the results of the analyses indicated that the steps taken by the Authority through whose area the stream passes prior to entering Ealing had been largely successful in eliminating contamination of the stream by sewage. Drainage and Sewage. Three houses previously connected to cesspools were connected to the Council's sewer during the year. At the end of the year arrangements were in hand for a further two houses to be connected. There are now only 28 permanent houses in the Borough not connected to the Council's sewers, of which 18 are in the Northolt Ward. Atmospheric Pollution. 140 Smoke observations were made by the Sanitary Inspectors and in 5 instances it was necessary to make representations regarding the emission of black smoke. In one instance the heightening of the boiler flue and the use of a better quality fuel succeeded in abating the nuisance. In two other cases improved methods of stoking effected an improvement and no further complaints were received. In another instance a temporary improvement was effected by the use of a better quality fuel but this was not wholly successful and at the end of the year other steps were being taken to abate the nuisance. In a further case, that of a large factory with oil burning furnaces, numerous complaints were received regarding the emission of sooty particles from the boiler flues. The Chief Sanitary Inspector and the District Sanitary Inspector concerned attended a meeting at the factory at which were also present representatives of the firm, representatives from the boiler manufacturers, and from the London Coal Tar Fuel Committee. As a result of this meeting measures were taken to improve the system of pre-heating the oil before it enters the furnaces and this was successful in abating the nuisance. Numerous complaints were also received regarding fumes given off from a yeast drying process in the Hanwell area. The management of the factory engaged a firm of specialists to instal an extraction and condensation system in an effort to abate the nuisance. At the end of the year a considerable improvement had been effected but adjustments were still being made to the plant in an effort to effect a still greater improvement. 34 Movable Dwellings. 1. Gypsy Caravans. During the year numerous complaints were received regarding the nuisance caused by gypsy caravans in the Northolt area. In recent years the problem of dealing with caravans of this type has become more acute owing to the urbanisation of many previously rural areas in West Middlesex. This has resulted in more active action being taken by the Councils in whose areas the gypsies were accustomed to park their caravans with the consequence that the caravans are kept constantly on the move and the gypsies take advantage of any undeveloped land, including that in the Northolt area, on which to find a temporary camping ground. Apart from the nuisance from the public health standpoint there is also the annoyance caused to residents in the area by horses straying, breaking down hedges and fences and damaging gardens. The extent of the problem may be gathered from the following figures : Year Number of caravans removed by the Sanitary Inspector by informal action or by pulling them on to the roadway with the assistance of the Police Number of Statutory Notices served Number of cases taken to local Magistrates Court Result of Court action 1949 318 57 9 Orders made for the removal of caravans. A fine of £1 was imposed in each of two cases Jan. 1950 to Feb. 1951 305 103 14 (relating to 33 caravans) In each case Orders were made for the removal of the caravans. Costs amounting to £4. 7s. Od. were awarded and fines amounting to £11 were imposed. 35 It should be emphasised also that the large number of caravans dealt with does not give a true indication of the number of separately occupied caravans coming into the district as, with a few exceptions, the majority belong to about twenty gypsies, who, after having been removed from one site in the district to a site outside the district, return after a lapse of a few days or weeks to another site in the Northolt area so that, in fact, we are constantly dealing with the same gypsies. We have secured Court Orders against fifteen of them prohibiting their using land in the Borough as camping sites for the parking of caravans and the Council are enabled thereby to take action against them at any time for contravening a Court Order should they again come into this District. It should be pointed out, however, that by the time application has been made to the Court for a summons and the summons has been issued, several days have elapsed and in many cases the caravans have left the district before the Court hearing. In other cases also, they have left the site before the summons can be served, so that no penalty can be inflicted by the Court. The only permanent remedy for this nuisance appears to be that of providing fences or barricades to prevent the access of gypsy caravans on to waste land. This policy has been followed in respect of certain sites in North Hanwell and Greenford with the consequence that very little nuisance from gypsies has been experienced in these areas for some time. Semi-Permanent Caravans. In 1949, as a result of the increasing number of movable dwellings of a semi-permanent type in the Northolt area, the Council took action under Section 345 of the Middlesex County Council Act, 1944, against the tenants of seventeen of these dwellings who were refused permission by the Council to use land in the Borough as sites for their movable dwellings. Seven tenants appealed against this decision to the Ealing Magistrates Court. Two of the appeals were withdrawn before the hearing and in the remaining five cases the appeals were dismissed by the Magistrates. The tenants were given until the 31st March, 1950, in which to find other accommodation. Early in 1950 three other caravan dwellers were refused permission by the Council to use land in the Borough as sites for their movable dwellings, making a total of twenty semi-permanent caravans. Arising from the Council's action and the dismissal of the appeals by the Court, twelve occupants of caravans voluntarily left the district; two were re-housed by the Council (one after being fined 20/- at the local Magistrates Court) ; two left after having been fined at the local Magistrates Court (20/- in one case and 40/- in the other) ; one served one day's imprisonment for nonpayment of a fine of 10/-, and his caravan has since been made the subject of a Demolition Order by the Council. 36 Of the three remaining, one has been fined 10/- on two occasions and 20/- on two occasions, another has been fined 10/- on one occasion, and 20/- on two occasions, and the third has had three fines of £2 inflicted by the Court. To summarise the position, only three of the original twenty semi-permanent caravans have not been satisfactorily dealt with. In these three cases legal proceedings have resulted in small fines being inflicted by the Court. The defendants' acute housing difficulties have no doubt influenced the Court in assessing the penalties, but it is improbable that small fines will have the effect of causing the occupants to remove their caravans from the District. Repairs to unfit houses. The rising costs of building repairs, and the operation of the Rents Restriction Acts in respect of certain classes of property have greatly increased the work of the Sanitary Inspectors in dealing with housing repairs and it is becoming abundantly evident that urgent consideration will have to be given to the problems arising from the age of properties and the inability of many owners to fund necessary urgent repairs from the current rent yield. The following table shows that since the immediate pre-war period, the number of complaints received by the Department has more than doubled, the number of Statutory Notices served has increased over five times and the number of cases taken to the Magistrates Court has increased seven times. Year Estimated Population Number of inhabited houses according to Rate Book Number of complaints received bySanitary Inspectors Number of houses found not to be in all respects fit for habitation Number of Preliminary Notices served Number of Statutory Notices served Number of cases relating to non-compliance with Statutory Notices taken before Magistrates Court 1931 117,900 29,473 768 855 5ii 61 — 1938 161,000 45,154 1,388 1,113 675 82 5 I950 188,800 49,831 3,008 1,646 1,299 421 36 Baths and Swimming Pools. The Council's swimming baths are equipped with pressure filters for continuous filtration, and the water is treated with chlorine under strict supervision. Four samples were taken by the Sanitary Inspectors during the year for bacteriological examination and in each case a satisfactory report was received. 37 There are three privately owned swimming pools in the Borough. Two of them are maintained by the staff recreation clubs of two large factories ; the other is provided in connection with several blocks of flats. Chlorine treatment is carried out at each of them. Public Mortuary. The arrangement with the Acton Council for the use of the Acton Mortuary was continued during the year. 174 Bodies were taken to this Mortuary and post mortem examinations were carried out in every case. I would once again emphasise that the provision of a public mortuary in Ealing is an urgent necessity. National Assistance Act, 1948. Under Section 50 of this Act the burials of five persons were carried out. In one case part of the expenses of the burial were recovered and in four cases the cost was borne by the Local Authority. FOOD HYGIENE. The Lecture Scheme for food handlers in the Borough which commenced in 1949, has continued throughout the year, apart from one short break during the summer recess. By the end of the year 76 lectures had been given, 9 by Dr. W. Howard Hughes, Director of the Public Health Laboratory, Ealing ; 17 by Dr. T. Anderson, Deputy Medical Officer of Health, Ealing ; 46 by the Ealing Sanitary Inspectors ; 2 by J. McClemont, B.Sc., N.D.D., National Agricultural Advisory Service, and 2 by Miss E. M. Laing, Information Officer, British Baking Industries Research Association. The course normally consists of five lectures : 1. General Aspects of Food Hygiene. 2. Food Infections and Food Poisoning. 3. Hygiene of Food Premises and Food Preparation. 4. The Individual Food Handler and his part in Food Hygiene. 5. The Law and Food. In the case of certain groups for whom special lectures were arranged, a shortened course of three or four lectures has proved to be sufficient. By the end of 1950, 514 persons engaged in the local food trades had enrolled for the course ; of which number 401 (or 78%) received Certificates of Attendance. 1,855 Attendances were recorded. It is evident from the high percentage of those completing the course that the lectures are of interest and value and it is gratifying to know that this view has been confirmed by the complimentary expressions of opinion we have received from many of those attending the lectures. The School Meals Service has co-operated very fully in the lecture scheme and by the end of the year the majority of the 38 supervisors, cooks and assistant cooks had attended the course. Arrangements are in hand for others in the School Meals Service including part-time helpers to attend the course of lectures. The organisation and administration of this Lecture Scheme, involving as it does, meetings with local food trade associations, interviews with local traders to enrol those willing to attend the course, arranging suitable dates and times for the lectures to be held, adjusting the syllabus to meet the requirements of the various classes of trader and attendance at lectures on many evenings throughout the year, has necessitated a considerable amount of additional work by the Chief Sanitary Inspector and his staff. It speaks well for the organisation that on no occasion since the Scheme commenced has any alteration had to be made in the date, time or subject of any one lecture. Towards the close of the year arrangements were in hand for a course of lectures to be given to the kitchen staffs of several of the large factory canteens. A meeting had also been arranged by the Borough Education Officer with the Head Teachers of the Grammar Schools and Secondary Modern Schools at which I outlined a Scheme for a short talk to school leavers on the subject of Food Hygiene. (This scheme has now been approved and arrangements have been completed for talks on the subject of Food Hygiene to be given by the Sanitary Inspectors to the School leavers at fourteen of the Grammar and Secondary Modern Schools in the Borough). In August, 1950, a meeting organised by the Central Council for Health Education in connection with the Food Fair at Olympia was held in the Town Hall, Ealing. The Mayoress (Mrs. H. Topping) welcomed the delegates, consisting of Members, Medical Officers of Health and Sanitary Inspectors from a number of Local Authorities. The Chairman of the Public Health Committee (Alderman Mrs. Leila H. Stowell) opened a discussion on the Ealing Clean Food Scheme which aroused considerable interest, and many delegates took part in the ensuing debate. In March, 1950, Byelaws regarding Clean Food based on the model approved by the Minister of Food, were adopted by the Council. A copy of these Byelaws has been circulated to every food trader in the Borough. Later in the year, an illustrated booklet setting out in nontechnical language the need for cleaner food handling and the methods for achieving it was prepared by the Deputy Medical Officer of Health and the Chief Sanitary Inspector. The booklet was approved by the Public Health Committee and circulated to every food trader in the Borough. As a result of the issue of this booklet, many new enrolments were received for our Lecture Scheme and a number of traders have expressed their intention of qualifying for the Council's Certificate of Hygiene. LECTURE ON FOOD HYGIENE IN PROGRESS AT THE TOWN HALL, EALING Ealing Borough Council Certificate of Hygiene has fulfilled the requirements relating to premises and staff imposed by the Baling Borough Council as a condition obligators to the issue of a food hygiene Certificate and this Certificate is granted in recognition thereof. Dated this day of 195 This is to Certify that Mayor Gown Clerk FOOD HYGIENE CERTIFICATE ISSUED BY THE EALING BOROUGH COUNCIL (actual size : 13 ins. x 18 ins.) 39 I am hopeful that in the very near future several local firms will have fulfilled the Council's very stringent conditions governing the issue of this Certificate and will have qualified for its award. At the request of a number of local food traders, I prepared a notice for exhibition on food premises requesting customers not to bring their dogs on to premises where food is prepared or sold. By the end of the year 131 traders had applied for this notice to exhibit in their shops. Notwithstanding a shortage on the Sanitary Inspectors' staff during the greater part of the year occasioned by our inability to fill vacancies caused by the retirement of two Sanitary Inspectors, a considerable amount of work has been carried out in the inspection of food premises. Many improvements have been effected and in several cases difficulties encountered over the issue of Building Licences have been overcome. It is anticipated that during 1951, with a full staff, the work of inspection and improvement of food premises will be accelerated. I am confident that the education of food trade employees in Clean Food handling together with the routine and systematic inspection of food premises are the two principal means by which a successful Clean Food Campaign may be achieved. The Medical Officer of Health has asked if, in the interests of hyyiene. customers would be so good as not to briny dogs into any shop which deals in the sale of food. 40 SANITARY INSPECTION OF THE BOROUGH General. Number of premises inspected on complaint 3,008 Number of nuisances observed by Inspectors 77 Number of premises visited in connection with infectious disease 510 Number of premises visited by periodical inspection (Dairies, Food Premises, Factories, etc.) 3,103 Number of houses inspected under house-to-house survey 28 Food inspections 1,059 Inspections of caravans and movable dwellings 629 Other inspections 1,841 Number of re-inspections 8,656 Total number of inspections and re-inspections 18,911 Number of Intimation Notices given 1,299 Number of letters written 2,810 Number of Statutory Notices served 470 Proceedings before Magistrates 57 Legal Proceedings. Public Health Act, 1936, Sec. 93. Non-compliance with Statutory Notices. In 32 cases legal proceedings were taken to enforce compliance with Notices requiring the abatement of nuisances. In 19 of these cases Orders were made by the Magistrates for the necessary work to be carried out within a stated period. In 3 cases proceedings were taken for non-compliance with Court Orders. Fines amounting to £5. 3s. Od. were imposed and Costs amounting to £20. 19s. Od. were awarded. In 10 cases the summonses were adjourned and later withdrawn as the work had been completed prior to the adjourned hearings. In a further 26 cases summonses were issued for non-compliance with Notices requiring the abatement of nuisances, but the summonses w7ere withdrawn before the hearings as the work in each case had been satisfactorily carried out. A further 5 cases were taken against the owners of gypsy caravans. In 2 cases Orders were made by the Magistrates for the abatement of the nuisances and Costs amounting to £2. 2s. Od. were awarded. In the other 3 cases fines amounting to £11. were imposed on the occupants of the caravans for non-compliance with Court Orders. Public Health Act, 1936, Sec. 75. The owners of two properties upon whom Notices had been served to provide dustbins appealed against these Notices to the Ealing Magistrates Court. In both cases the appeals were allowed. 41 The Ealing Council appealed against this decision to the Middlesex Quarter Sessions who allowed the Appeals and awarded £10. 10s. 0d. Costs to the Council. Middlesex County Council Act, 1944, Sec. 345. The occupants of 8 caravans of a semi-permanent type in the Northolt area were summoned for continuing to occupy land in the Borough as sites for their movable dwellings after the Ealing Council had refused them permission to do so. 13 Cases were taken before the local magistrates court and in 12 cases fines were imposed amounting to a total of £14. 10s. Od. and in the remaining case the defendant received an absolute discharge. FOOD AND DRUGS ACT 1938. FOOD AND DRUGS (MILK, DAIRIES AND ARTIFICIAL CREAM) ACT 1950. MILK AND DAIRIES REGULATIONS 1949 ETC. Inspections of Milk Purveyors' Premises 109 Contraventions of Acts, Orders or Regulations 3 Samples of Milk taken 40 Inspections of Food Premises 2,243 Contraventions found 131 Inspections of Ice Cream and Synthetic Cream Premises 389 Samples of Ice Cream and Synthetic Cream taken 113 Samples of other Foods taken 16 Legal Proceedings. Food and Drugs Act, 1938, Sec. 9. The following three cases relating to the sale of unsound food were the subject of legal proceedings : 1. Unsound Chocolates—fined £5 (10/6 Costs). 2 and 3. (Two offences). Unsound Rabbits—fined £10. (£1. Is. Od. Costs). Milk Supply There are 76 registered distributors of milk in the Borough. At the commencement of the year licences for the milk under the Milk (Special Designation) Regulations were as follows : sale of granted Dealers' Licences Supplementary Licences Total Tuberculin Tested Milk 48 9 57 Pasteurised Milk 46 11 57 vSterilised Milk 41 10 51 42 Thirty-eight samples of pasteurised milk were taken and submitted to the methylene blue and phosphatase tests at the Public Health Laboratory, Ealing. All passed the methylene blue test, but 2 failed the phosphatase test. These were processed outside the Borough and the Authorities concerned were informed. Subsequent samples were satisfactory. In addition, 250 samples of pasteurised milk from processing plants in the Borough were taken by officers of the County Council, who are the Licensing Authority under the Milk (Special Designation) Regulations. Of these, 3 failed the methylene blue test and 2 failed the phosphatase test. Ice Cream. . Eighty-one samples of ice cream were taken during the year and were submitted for bacteriological examination to the Public Health Laboratory, Ealing. The results in accordance with the provisional grading scheme recommended by the Ministry of Health, were as follows : Provisional Grade No. of Samples Presumptive Coliforms Present Faecal Coliforms Present 1 40 3 Nil 2 23 17 Nil 3 6 5 Nil 4 12 11 1 Totals 81 36 1 Unsatisfactory samples were followed up, either by investigation at the producer's plant in the Borough, or by notification to the Authorities concerned where the manufacturers' premises were outside the Borough. Synthetic Cream. Twenty-one samples of synthetic cream were obtained from local manufacturers ; 19 received satisfactory bacteriological reports. The 2 samples which were not up to a satisfactory bacteriological standard were found to be due to contamination of one of the raw materials with a non-pathogenic spore-forming organism. 43 The following foodstuffs were condemned by the Sanitary Inspectors as unfit for human food in the course of their inspections of the various food premises in the Borough : lbs. Bacon 147½ Beef 773 Biscuits 504 Brawn 501½ Butter 86 Cake 186 ¾ Cereals 445 Cheese 186 Chickens 70 Cocoa Butter 234 Condensed Milk 280 Confectionery 8,691¼ Cooking Fat 71¾ Corned Beef 555 Corned Mutton 12 Custard Powder 993 Dried Fruits 450¼ Fish 6,554 Flour and Bakery Waste, etc. 19,382 Fruit and Vegetables 1 Ham 36¼ Jam, Marmalade, Syrup, Treacle 736½ Lamb 508¼ Luncheon Meat 152 ¾ Margarine 58¼ Meat 116½ Minced Beef Loaf 1 Mincemeat 6 Nuts 2,192 Oats 49 ½ Offal 68 Pork 4 Rabbit 78 Sausages and Sausage Meat 52½ Sugar 6 Suet 4½ Tea 160¾ Tripe 28 Veal 56¼ Meat and Other Foods. 44 In addition, the following other articles of food were also condemned : Eggs (liquid) 70 lbs. Eggs (shell) 11,802 Assorted tins, jars and packets 29,813 There are two private slaughterhouses in the Borough, but no slaughtering has been carried out in them since 1939. HOUSING STATISTICS. 1. Inspection of dwelling-houses during the year : (1) (a) Total number of dwelling-houses inspected for housing defects (under Public Health or Housing Acts) 2,229 (2) (a) Number of dwelling-houses (included under sub-head (1) above) which were inspected and recorded under the Housing Act, 1936 28 (3) Number of dwelling-houses found to be in a state so dangerous or injurious to health as to be unfit for human habitation 5 (4) Number of dwelling-houses (exclusive of those referred to under the preceding sub-head) found not to be in all respects reasonably fit for human habitation 1,646 2. Remedy of defects during the year without service of formal notices : Number of defective dwelling-houses rendered fit in consequence of informal action by the Local Authority cr their officers. 1,528 3. Action under Statutory Powers during the year : A.—Proceedings under Section 9, 10 and 16 of the Housing Act, 1936 : (1) Number of dwelling-houses in respect of which notices were served requiring repairs — (2) Number of dwelling-houses which were rendered fit after service of formal notices : (a) by Owners (6) by Local Authority in default of Owners — B.—Proceedings under Public Health Acts : (1) Number of dwelling-houses in respect of which notices were served requiring defects to be remedied 421 (2) Number of dwelling-houses in which defects were remedied after service of formal notice : (a) by Owners 345 (b) by Local Authority in default of Owner 3 45 C.—Proceedings under Section 11 and 13 of the Housing Act, 1936 : (1) Number of dwelling-houses in respect of which Demolition Orders were made 3 (2) Number of dwelling-houses demolished in pursuance of Demolition Orders — (3) Number of houses concerning which action has been taken by the Local Authority under Section 19, and with respect to which Owners have given an undertaking that they will not be used for humau habitation D.—Proceedings under Section 12 of the Housing Act, 1936 : (1) Number of separate tenements or underground rooms in respect of which Closing Orders were made 2 (2) Number of separate tenements or underground rooms in respect of which Closing Orders were determined, the tenement or room having been rendered fit ... The Town Council completed 378 permanent dwellings during the year, comprising 94 houses with 3 bedrooms, 30 houses with 2 bedrooms, and 12 houses with 1 bedroom ; also 174 flats with 2 bedrooms, 52 flats with 1 bedroom and 16 bed sitting room flats. In addition, 67 houses were built by private enterprise. FACTORIES ACTS 1937 and 1948. 1. Inspections for the purposes of provisions as to health (including inspections made by Sanitary Inspectors) : Premises Number on Register Number of Inspections Written Notices Occupiers prosecuted (i) Factories in which Sections 1, 2, 3, 4 and 6 are to be enforced by Local Authorities 246 117 6 - (ii) Factories not included in (i) in which Section 7 is enforced by the Local Authority 390 255 14 - (iii) Other Premises in which Section 7 is enforced by the Local Authority (excluding out-workers' premises) - - - - Total 636 372 20 - 46 2. Cases in which defects were found : Particulars Number of cases in which defects were found Number of cases in which prosecutions were instituted Found Remedied Referred To H.M. Inspect'r By H.M. Inspect'r Want of cleanliness 2 2 — — — Overcrowding — — — — — Unreasonable temperature — — — — — Inadequate ventilation — — — — — Ineffective drainage of floors — — — — — Sanitary Conveniences : (a) Insufficient 6 6 — 2 — (6) Unsuitable or defective 8 8 — 1 — (c) Not separate for sexes — — — — — Other offences against the Act (not including offences relating to outwork) 4 4 — — — Total 20 20 — 3 — Part VIII of the Act. Outwork. (Sections 110 and 111). Nature of work Section 110 Section 111 No. of out-workers in August list required by Sect. 110 (1) (c) No. of instances of work in unwholesome premises Wearing apparel : Making, etc. 120 — Cleaning and washing 1 — Furniture and upholstery 4 — Paper bags 6 — Making of boxes or other receptacles or parts there of made wholly or par tially of paper 6 — Carding, etc., of buttons, etc. 2 — Stuffed toys 21 — Cosaques, Christmas crackers, Christmas stockings, etc. 4 — Total 164 47 Section 54—Basement Bakehouses. A survey of the two remaining basement bakehouses in the Borough was carried out during the year. In one case, the Council were not satisfied that the bakehouse was suitable for use as such and the Certificate was withdrawn. In the other case, the Certificate was renewed for a further period. Shops Act 1950. In co-operation with the Shops Act Inspector, improvements under Section 38 of the Shops Act 1950, relating to the health and comfort of shop workers, were carried out in 30 instances. Improved means of maintaining a reasonable temperature were secured at 10 premises ; improved sanitary accommodation at 13 premises ; lighting was improved in 1 case, and washing facilities improved in 6 cases. Summary of Sanitary Defects remedied as a result of Notices served and Letters written. Animals—nuisances from abated 21 Caravans—nuisances from abated 338 Cesspools—abolished 3 Cesspools—cleansed 8 Drains—connected to sewer 3 Drains—cleared and cleansed 384 Drains—reconstructed 39 Drains—repaired 172 Drains—new soil or ventilating pipes provided 15 Damp proof courses inserted in walls 32 Dampness—other forms remedied 235 Dustbins—provided 205 Floors—repaired 123 Floors—sub-floor ventilation provided 19 Food premises—improvements carried out. 138 Food Cupboards ventilated 4 Refuse—accumulations removed 81 Roofs, eaves gutters and rainwater pipes repaired 671 Sinks and waste pipes repaired or renewed 69 Walls and ceilings repaired and cleansed 1,324 Water supply re-instated 63 Water supply—draw taps fixed to main supply 13 Water closets—repaired, reconstructed or improved 160 Yards paved or repaired 40 Other defects remedied 853 48 PREVENTION OF DAMAGE BY PESTS ACT, 1949. The following is a summary of the work carried out by the Rodent Operative acting under the supervision of the Chief Sanitary Inspector: Complaints 733 Premises inspected 919 Premises found to be infested wit: (1) Rats 559 (2) Mice 257 Re-visits to infested premises 1,595 Fees received for treatment £616. 11s. Od. Premises treated free of charge. 120 In accordance with the requirements of the Ministry of Agriculture and Fisheries, Infestation Control Division, maintenance treatments of the soil sewers in the Borough were carried out during March and July. A total of 1,001 sewer manholes were dealt with and of these 644 were found to be rat infested. Poison baits were used in the infested manholes. The regular and systematic poison baiting of sewers is an important part of the work of rat destruction in the Borough. DISINFECTION. Rooms disinfected by spray: (а) Ordinary Infectious Disease 29 (b) Tuberculosis 79 (c) Other conditions 62 Houses treated for vermin 126 Articles disinfected by steam: (а) Ordinary Infectious Disease 8 (b) Tuberculosis 46 (c) Other conditions 138 Articles voluntarily destroyed 278 THE END OF EALING'S HOSPITAL SERVICES. The transfer of hospital powers from the Borough to the Regional Board did not entail an immediate break in the continuity of administration and up to the middle of 1950 the two hospitals were still under the supervision of the Medical Officer of Health. The clinical staffing of both Perivale and Clayponds Hospital was carried out by Assistant Medical Officers of Health. 49 The Hospitals Management Committee of the Regional Hospital Board, however, decided that it was desirable for administrative purposes that these arrangements should be discontinued and their own officers should be administratively and clinically in control of the two hospitals. This inevitably meant a break in the Maternity and Child Welfare services which had been built up largely on the basis of Perivale maternity hospital being available for the difficult cases found at Ante Natal Clinics, and also its officers specialising in maternity work were enabled to keep in constant touch with the practical working of modern obstetric practice. The new arrangement by which the hospital staffing is carried out by two whole-time Resident Medical Officers of Registrar grade and a part-time consultant must be compared with the staffing under the Local Authority of a part-time consultant available on call and for regular weekly visits, combined with half-time of an Assistant Medical Officer of Health acting as Resident Medical Officer, whilst other Assistant Medical Officers of the Borough gave regular weekly service in order to relieve the Resident. The medical and administrative arrangements at Perivale Maternity Hospital were most efficient and yet most economical. The same remarks apply also to Clayponds Hospital, where a similar system of medical staffing and of administrative supervision were carried out. Here again a link with the Infectious Disease work with the general public health administration was a logical and efficient method of dealing with a local problem. The transfer away from the Local Authority of Clayponds Hospital has unfortunately led to a complete breakdown in the arrangements for tonsillectomies for the school service. It had been the practice for many years to undertake a small list of tonsil and adenoid operations each week at this hospital. The consultant employed by the Ealing Council had undertaken the work and this arrangement was continued until 1950 when the Regional Hospital Board took over the hospital and used it for orthopaedic purposes rather than for infectious disease. This led, of course, to a piling up of our waiting list of children needing tonsillectomy, and in spite of our appeals to the local Hospital Management Committee to find some way of helping us out of our dilemma there has been no response to our request for action to be undertaken to deal with our growing list of cases. A review has periodically been made to try to get down the list as far as possible but in spite of this over 600 children were on the waiting list in November, 1950, and this number has increased since then. I regret that I must report this but the necessity for speedy action to deal with this problem is of great importance and I hope that the responsible authorities will find a solution in the near future. Much avoidable ill-health and distress is being caused by this breakdown of expensive hospital services. 50 SCHOOL HEALTH SERVICE. The administration of the School Health Service continues to be a function of the Middlesex County Council. The local Education Divisional Executive makes the arrangements for medical examination while the Area Health Committee arranges for treatment and disposal of the children. The number of children on the school registers has increased from 7,492 in 1920 to 22,622 in 1950. During the year 6,630 children were seen at routine examinations (6,885 in 1949) and 2,321 were seen again at "follow-up" inspections. In addition, another 3,511 children were referred by the teachers, school nurses and parents for special examinations by the doctors. This means a total of 10,141 children were seen by the school doctors during the year—or almost 50% of the number on the register. The ideal is the annual examination of every child and while this is not yet practicable, there can be few conditions that escape the notice of nurse, parent, teacher and doctor. At the end of the year the Borough was divided into six areas, and one assistant medical officer was made responsible for the health of the children in each area. This system ensures that the same doctor attends the antenatal clinic, child welfare clinic and school clinics in the district. The mother and child thus come to know, trust and respect the doctor. A much more personal relationship develops under such circumstances than in a departmentalised system where each doctor specialises in one type of clinic. Under the latter system the anxious mother is confronted by a succession of new faces in her transit from one clinic to the next. The doctor also benefits, for instead of seeing a "series of cases," he knows the mothers and children as individuals and finds great interest in following their progress and development. The child at the clinic is no longer considered as an isolated unit but as a member of a family group. Children are examined as routine on entry to school, in their last year at the junior school, and finally in the last year at the secondary school. This "leavers" examination is of great importance to the child's future career. Recommendations are made to the Youth Employment Officer should any physical or mental handicap exist which makes certain occupations unsuitable. 51 The fitness of each child is roughly assessed by the examining doctor as good, fair or poor. Such a classification must depend largely on the standards of the examiner but of the 6,630 inspections carried out only 79 children were put into the "poor" group, i.e., 1.2%. This compares with 2.5% in 1949 and 3.8% in 1920. Rates of up to 5½% have recently been recorded in other areas of Middlesex. The number of children found at routine medical examinations to require treatment has fallen substantially at each inspection— from 816 in 1949 to 537 in 1950. The number of children found at routine and special inspections to be suffering from certain defects fell substantially as may be seen from the following : 1949 1950 Skin diseases 901 617 Defective vision 409 358 Squint 51 24 Defects of hearing 45 36 Middle ear disease 42 33 Nose and throat 589 350 Speech 70 33 Enlarged glands 11 5 Heart and circulation 14 5 Lung diseases 101 35 Hernia 15 1 Postural defects 34 17 Flat foot 114 86 It is therefore not surprising that the number of attendances at the Minor Ailment clinics declined slightly from 3,871 in 1949, to 3,299 in 1950. A large number of these children now receive their treatment from the General Practitioners and Hospital out-patient departments. The function of the Minor Ailment Clinic is tending to change. It is now a clearing house for various special cases such as children in whose cases the diagnosis is in doubt, ascertainment of physically handicapped and educationally sub-normal children and the treatment of minor degrees of maladjustment. The early treatment of apparently minor conditions may prevent much serious disease in later life. Children that present with apparently trivial symptoms are occasionally found suffering from serious organic disease. 52 OPHTHALMIC SERVICE. Children with defects of vision are referred from the school doctors and minor ailment clinics to the care of the Consultant Ophthalmologist, Mr. Freeman Heal. There has been a marked fall in the number of children for whom glasses were prescribed, but this is in part due to a revised recording system. This year's figure of 256 relates to the number of new cases only and not to replacements or modifications of existing spectacles. The prescription is dispensed by the optician of the patient's choice, and the delay is now much less than in the early days of the National Health Services. No charge is payable for school children's spectacles provided under the provisions of the National Health Service Act. EAR, NOSE AND THROAT SERVICE Mr. Arthur Miller, Consultant Otologist, conducts special clinics during alternate weeks at Mattock Lane and Ravenor Park Health Centres. Cases are referred from the teachers, doctors, minor ailment clinics and school nurses. The waiting list for operations has reached serious lengths owing to the few children operated on each week and suspension of tonsillectomy during the summer months. It has not been found possible to arrange with the Regional Hospital Board for priority treatment of children referred from the school clinics. Only the most urgent cases are now being considered for operation. Some of the children with conservative treatment do eventually improve to such a degree that operation is not required. Apart from tonsils and adenoids much valuable work is done in the treatment of various forms of deafness, ear diseases, infections of the para-nasal air sinuses and the mastoid antrum. Forty-six children were operated on during the year under arrangements made by the Authority and 84 received treatment at the local hospitals. ORTHOPAEDIC SERVICE. The clinics deal with various types of deformity including children with poor posture and many early foot defects. A number of children disabled by more serious conditions such as poliomyelitis or birth injury receive valuable help and follow-up treatment. 53 Two special clinics have been started to teach children with asthma certain breathing exercises. Mr. J. A. Cholmeley, Consultant Orthopaedic Surgeon, attends Mattock Lane and Ravenor Park Health Centres, during alternate weeks. 60 cases were admitted to hospital and 202 others received corrective treatment from the two physiotherapists at the clinics. SPEECH CLASSES. Speech Therapy In addition to the routine work of the department, an under-five play group for retarded speech cases was started during the year. The children are taken in groups of six and encouraged to indulge in active noisy play for 30 minute periods. Into the games are introduced various vocal noises such as hooters, trains, motor cars and bells. A quieter period of table play with plasticine, picture books and drawing is used to encourage conversation between the children. The session is ended with a 15 minute period of simple stories of the repetitive type (e.g., the "Three little pigs") in which the children join spontaneously. Nursery rhymes or games to music sometimes replace the story. Several children who entered this group quite inarticulate at four years have entered school at five with an understandable language. A "follow up" group for stammerers has been maintained during the year. This group is encouraged to build and organise a puppet theatre. The creative work involved helps to remove inhibitions and encourage a free flow of language; progress can thus be carefully observed. Other activities during the year included the treatment of the following children : Dyslalia 107 Stammer 35 Aphasia 4 Cleft palate 4 Other conditions 3 Total 153 Treatment is carried out by Miss Sawkins and her staff. Mrs. Pauer, Speech Therapist Assistant, resigned in July and was replaced by Miss M. Sorby. 54 Classes are held at the following centres : Mattock Lane 5 sessions weekly Cherington House 2 „ „ Ravenor Park 1 session ,, Greenford Green 1 „ „ Perivale 1 „ „ Oldfield School 1 „ „ Northolt School 1 ,, ,, Total 12 sessions „ EMPLOYMENT OF CHILDREN AND YOUNG PERSONS. No child is permitted to be employed under the age of 13 years, and more than hours on any school day, or five hours on a holiday. 227 pupils were medically examined to determine if they were fit for employment outside school hours. In 4 cases permission was not granted. Eighteen children were examined and found to be fit to take part in entertainments. EXAMINATION OF TEACHERS. 76 teachers were medically examined on appointment to determine their physical fitness for their duties. INFESTATION WITH VERMIN. The standard of cleanliness remains at a very high level. Only 493 children were found to be infested after 48,381 examinations, i.e., just over 1 per cent. (this compares with 2 per cent. for the County of Middlesex as a whole.). In no case was a compulsory cleansing order served. There remain a number of chronic offenders but example and persuasion are used to assist them reach a better standard of hygiene. A number of improved insecticidal hair lotions perfected in the past 10 years have greatly reduced the severity of this problem and simplified the treatment. 55 HANDICAPPED CHILDREN. An important duty of the school health service under the provisions of the National Health Service Act of 1944, is to examine children who are suffering from some handicap of mind or body so as to require special educational treatment. At the end of 1950, the following number of children in Ealing, of school age, has been formally ascertained : Blind 2 Partially sighted 7 Deaf 14 Partially deaf 14 Delicate 160 Diabetic 7 Educationally sub-normal 96 Epileptic 9 Maladjusted 75 Physically handicapped 31 Speech defects 4 Multiple defects 3 Of these 159 had been placed in special residential schools, 45 in special day schools, 6 in independent schools, 9 received home tuition and 203 were in maintained primary and secondary schools. Thus almost half the children were suffering from defects of so mild a nature that they were able to be fitted into ordinary school life. The blind and deaf children usually require treatment at special residential or day schools where they receive training in appropriate trades. The partially deaf and partially sighted children can often be kept in an ordinary school if they are given a favourable place in class and some special tuition. Educationally sub-normal children require various types of education suitable to their age, ability and aptitudes. This ranges from opportunity classes in ordinary schools to day or residential special schools in the more severe cases. The waiting list for such schools is necessarily long and must so remain until more schools can be provided. Delicate children are provided with extra nutrients and rest. An open air school may be recommended in the more severe cases. Diabetic children are cared for in special residential schools. The children live in hostels under constant medical and nursing care and are taught how best to care for themselves. 56 DENTAL SERVICE. This service has now been transferred to the Middlesex County Council. It has been maintained during the year in spite of severe staff shortage. There are at present three full-time dentists and one part-time orthodontist who works five sessions weekly. Full treatment has been restricted to the 5-7 year age group, and emergency treatment given to other children. In all cases of toothache or other acute and serious conditions priority service is available. During the year this was requested in 3,400 cases. A free dental service is provided for the public under the National Health Service Act. The older children are now being referred to the care of their family dentist. At present approximately one-third of the dental care of school children is being carried out by the school dental service. Two new clinics are under construction at Laurel House, Northfields, and Abbey Parade, West Twyford, and these will provide modern treatment facilities when completed. The existing clinics have been re-equipped and facilities are now very satisfactory. Expectant and nursing mothers are offered priority treatment when attending the ante- or post-natal centre. The amount of work undertaken for the pre-school children has greatly increased due to better awareness by the parents of the value of early conservative dentistry. There has been a substantial increase in the number of temporary fillings 4,282 (1,369 in 1949) and a decrease in the number of extractions 6,909 (7,822 in 1949), showing the tendency to conserve the teeth wherever possible. The orthodontic service continues to be much in demand and the number of cases treated during the year was 258 as compared to 185 in 1949. ASCERTAINMENT AND TREATMENT OF DEAFNESS IN SCHOOL CHILDREN. On 23rd January, 1950, a scheme was started in Ealing to test the hearing of school children. Children were taken in classes of 40 and a mass test applied by a nurse, who had received special instruction in the use of the gramophone audiometer. About 20% of children failed the first test and these were then re-tested, when the number of failures were usually reduced to 12%. Cases of temporary deafness were due to such matters as colds and wax in the ears. Middlesex County Times AT THE ORTHODONTIC CLINIC Middlesex County Times AUDIOMETRY 57 If a child failed a second test, it was referred to the Minor Ailment Clinic and there treated by the School doctor. These children were then re-tested for a third time after treatment and the number of failures then amounted to only 3.3%. The children who failed, received a more comprehensive test, using the "pure tone" audiometer and were then referred for examination by an ear, nose and throat specialist. These tests often reveal "one ear" deafness and by proper siting in class with relation to the teacher, a child may be helped greatly in its studies. Parents and staff have all co-operated enthusiastically and the work is continuing. Number of schools visited during the year 30 Number of children examined 8,398 Number of children with hearing loss 272 (i.e., 3.23%) Number of "pure tone" tests 52 Number of children seen by the Ear, Nose and Throat Specialist (Mr. Miller) to December 31st, 1950 4 Defects found include catarrhal deafness (70%), perforated ear drums (10%) and chronic mastoid disease (20%). FOOT HEALTH IN EALING The Contributory Shoe Scheme. During the past few years school medical officers have been concerned about the number of children leaving school who show the beginnings of trouble with their feet. A survey taken on Ealing school children showed that many of these foot troubles were due to badly fitting shoes and this agreed with investigations in other places. The Area Health Committee for No. 7 Area of the Middlesex County Council, on my advice, decided to organise a scheme whereby children should have their feet examined regularly by the school doctor to detect early trouble and should be fitted with good quality shoes by experienced shoe-fitters. Based on this principle, the Ealing Contributory Shoe Scheme was started in September, 1949. The manufacturers of "Start-rite" shoes were approached and offered to co-operate. For the first year the scheme was limited to children in the area of Mattock Lane Health Clinic and children attending Grange School. The scheme offered three pairs of "Start-rite" shoes, a service of expert fitting and repairs, and medical supervision of the children's feet. The cost was covered by payment of a sum varying with the child's age on entering the scheme. 58 The number joining the scheme in September, 1949, was eighty-four. This was a comparatively small number, although many more parents had appeared interested and the general comment was that there was difficulty in paying a lump sum down on entry to the scheme. It was also suggested that the cost was rather high. In view of this comment a survey of a sample of Ealing children was taken to find out how much parents were spending on footwear. This showed that the cost of the Shoe Scheme was on the whole very close to the average paid by a representative sample of Ealing parents. For example, the "average" parent of a six year old child paid out £4. 11s. Od. during the year for strong shoes and repairs; a Shoe Scheme parent paid £4. 17s. Od., which is very little more. The problem of a complete initial payment was, however, a real one and when the scheme entered its second year it was possible, through the help of the W.V.S., to organise an instalment system, a service which has been appreciated by the parents. The children received regular medical supervision and it is gratifying to see that while at the beginning of the Scheme (of the 84 children) nineteen children had no defect found in their feet, at the end of a year fifty-five were classed as perfect. In particular, corns and callouses, cramped and curled toes and bent great toes, were cured by wearing suitable shoes and socks. As these ailments are the cause of much discomfort in adults, it is especially important to recognise that they can be largely prevented by providing children with properly fitted shoes. As well as these medical findings, information of the rate of growth of the children's feet was obtained and the importance of a range of shoes which carries half sizes and three or four fittings became clear. When shoes are supplied from such a range most parents found that three pairs of strong shoes were sufficient for the year apart from summer sandals and Wellingtons, but the amount of repairs required by individual children varied greatly, so that for the next year, which started on the 1st October, 1950, it was decided to omit the repair service and to include one pair of sandals instead. At the end of the first year, parents were invited to make comments on the scheme. Their letters showed that without exception they appreciated the service and hoped that it would be continued. For the current year the scheme was opened to children attend ing Northfield School as well as children at Grange School and at Mattock Lane Welfare Centre, and 172 children are now participating in the scheme. THE SHOE SCHEME Daily Mirror 59 Routine Foot Inspection. Commencing in June, 1950, a school nurse with special training in the subject has been carrying out inspections of feet and footwear in the schools. The parents are notified of any foot trouble found and are given an appointment to attend the Chiropody Clinic or the Minor Ailment Clinic from whence, if necessary, they may be referred to the Consultant Orthopaedic Surgeon. Children who are found to be wearing too small or otherwise unsuitable footwear, are given a leaflet on "Children's Shoes" issued by the Boot and Shoe Research Association, to show to their parents. It is estimated that each child will receive a routine foot examination once in two years, and those requiring special care will be seen more often. Children with minor foot deformities such as corns, ingrowing toenails and hard skin are referred to the care of the Chiropodist. This is a completely new development in the care of the physique of the school child and we are extremely interested to observe its development. The parents are showing a lively interest, and it is hoped to be able to present some statistics at the end of a year's working on this side of the scheme. Already new lines of thought are being raised, and new approaches to the problems before us are appearing. Dr. Craigmile is supervising this specialist side of the work and is achieving promising results under most difficult circumstances. Number of schools inspected to 31st December, 1950 15 Total number of children seen 4,504 Referred to Minor Ailment Clinic 206 Referred to Chiropodist 118 Number of Verrucae found 53 A full report and statistical summary is now in preparation and the results are to be published shortly. CHILD GUIDANCE Dr. Holman reports:— "In 1950 it was found possible to see rather more new cases than had been seen in 1949. There were, however, a large number of cases waiting to be seen from 1949 and, in spite of all efforts in 1950, 50 cases remain on the waiting list for interview in 1951. This represents three to four months' work. We were able to institute treatment in a larger number of cases in 1950 than in 1949 and hope that this will not slacken in future years. Mrs. Charlotte Carey eventually joined our staff as a full-time Child Psycho-therapist in May, 1950. In future 60 years we will have the benefit of her services throughout the year and the time between a child's first being seen in the clinic and being taken on for treatment should be reduced. It is still a matter of concern to us that children and their parents referred to us have to wait such a long time. Once children begin treatment, they continue to attend on an average for 8 or 9 months. These periods of treatment almost invariably include holidays either of the staff or the child, so that the actual period of treatment is more like six months. As each child attends for less than an hour, this expenditure of time on modifying behaviour disorders and disturbed family relationships of great severity cannot be regarded as excessive. I do not think that it would be possible to reduce the amount of time devoted to each case. Symptoms and Problems. The symptoms for which children were referred show few differences from previous years. The method of classification is that prepared by the National Association for Mental Health many years ago and is in use in Child Guidance Clinics throughout the country. It is a convenient classification of the symptoms but fails to give an adequate indication of the severity of the different problems or of the factors in the background which contribute to the manifestation of symptoms. From our own point of view the symptoms are less important than the problems from which they arise. As has been stressed in other reports, the central problem of child guidance is disturbed family relationships. One might say that there are three classes of disturbance : 1. The child-parent relationship is basically good but has been adversely affected in some way. 2. The child-parent relationship is bad. 3. The child-parent relationship is non-existent (children who have been brought up in institutions and boarded out or placed in hospital in early life, etc.). Special Educational (Residential) Treatment. Twenty-four children were recommended for special educational treatment in 1950. These recommendations did not relate to the 178 children referred to the Centre in 1950, but to those referred in 1950 and those brought forward from 1949. The number so recommended amounts to just under 10%. This is in close agreement with the figure found in other years. A problem of very great importance is the suitable placement of these children. They come to us nearly always as a matter 61 of urgency. Either their families or their schools find them quite intolerable, or we are informed by some reliable agency (N.S.P.C.C. Children's Department, Head Teacher, etc.) that the home is quite intolerable for the child. We are faced with two difficulties: (1) that of finding a school suitable to the child's age, intelligence and degree of disturbance; (2) that of obtaining a vacancy. The procedure of ascertainment inevitably takes some time. However urgent the need may be, it is nearly always possible for child and parent to accept some period of waiting, provided it is short; and above all, provided it is finite. What has been so disturbing, not only in 1950 but in previous years, has been the length of the period of waiting, the uncertainty, and the tendency for cases to be overlooked unless continued enquiries are made of the local or County departments concerned. The average time between the sending in of our recommendations on Form 2 H.P. and the placement of a child in a special school, calculated from 55 cases sent away in 1949 and 1950, was about 4½ months (it is not possible to be quite precise as there are two cases still waiting after more than 18 months), but half the children had to wait six months or longer, and 10% of them nine months or longer after the recommendation on Form 2 H.P. has been sent off by us. During this time it often appears as if the whole energies of the Child Guidance Clinic were given to the problems of one family. If our Psychiatric Social Workers were free from the unconstructive work that seems to follow recommendations for a place in a special school, they would have very much more time for constructive work with the most favourable class of problem. Staff and Premises. The staff of the Ealing Child Guidance Clinic has been increased in 1950, first by the appointment of Mrs. Carey as full-time Psycho-therapist; secondly, by the appointment of Miss Hitchfield as second Educational Psychologist. It will be obvious from what has been said above that we can use the services of these workers to the full. Clerical Staff. We have repeatedly put forward our need for further help on the clerical side. It is not necessary to repeat the arguments here, but experience has shown that two workers in the office are indispensable if telephone and door are to be attended to while typing and secretarial work are done. As we have not a second clerk, one of the Psychiatric Social Workers or another member of the staff frequently has to act as second clerk, and this is a further waste of time and skill which should not be afforded while we have such a waiting list. 62 Items of Interest in 1950 Two external events have affected the Child Guidance Clinic this year : (1) The Chairman of the Middlesex County Council called a meeting on juvenile deliquency early in the year, as a result of which local committees have been set up in the Petty Sessional Divisions. The Psychiatrist from the Ealing Child Guidance Clinic and Miss Wilson, the Educational Psychologist, were asked to serve on the Brentford Committee, which first met in September, 1950, and will be reporting to the Chairman of the Middlesex County Council in 1951. (2) The Ministry of Education appointed a Committee of Enquiry into the treatment or maladjustment in children. All Child Guidance Clinics have been interested in this Committee in various ways. The Ealing and Twickenham Clinics jointly have prepared evidence for the Committee. The Psychiatrist of the Child Guidance Clinic has been asked to serve on a Committee of the Royal Medico-Psychological Association preparing more general evidence for the Committee and has been invited by the Committee to give individual evidence. This work is a matter of the very greatest interest and importance but has taken a good deal of time in 1950, and will take up still more time in 1951. The material for the evidence for the Committee is available in this and the Twickenham Clinic, but not in a form in which it will be useful. Much as we should like to use the information available to us for research purposes, in the ordinary way we have not the time. It will, therefore, be necessary to make a special effort to compile statistics that will be of value to the Ministry's Committee of Enquiry and this will involve a great deal of work in the examination of old and current cases. This is another undertaking which may interfere with the normal work of the Clinic in the coming year, but we feel that it is of the first importance to do what we can to assist this Committee whose findings will affect our work for years to come." 63 MATERNITY AND CHILD WELFARE AND OTHER SERVICES. Table showing Birth-Rate, Death-Rate and Infant Death-Rate for the Borough of Ealing. Period Birth-Rate Death-Rate Infant Death-Rate 1931—1935 14.2 10.1 46 1936—1940 14.7 10.1 45 1941 14.5 10.9 49 1942 17.2 10.3 48 1943 18.8 11.2 40 1944 19.4 10.9 41 1945 17.2 10.1 40 1946 19.7 10.1 27 1947 19.9 10.5 37 1948 15.7 9.2 26 1949 14.4 9.9 21 1950 13.7 9.5 26 Maternal Mortality per Thousand Births. Period Ealing England and Wales 1931—1935 4.10 4.12 1936—1940 2.18 2.95 1941 1.53 2.23 1942 1.79 2.01 1943 2.95 2.29 1944 0.97 1.93 1945 — 1.79 1946 0.84 1.06 1947 0.80 1.17 1948 1.36 1.02 1949 1.09 0.98 1950 0.75 0.86 64 Prematurity. The remarkable decline in the infant mortality rate over the last half century has not run parallel with a corresponding fall in the neo-natal mortality, that is the deaths of babies before the end of the first month of life. One of the largest factors keeping up the neo-natal mortality rate is prematurity ; this accounted for just under 50% of all neo-natal deaths in 1949. A premature baby is defined as a baby weighing 5½ lbs. or less at birth. While comparatively little advance has been made in discovering the cause, medical science has made great strides in the care of these babies and many more survive than in former years. In the latter part of 1948 and the beginning of 1949 a scheme for the care of premature infants was prepared and adopted in Area 7, now administered by the Middlesex County Council. This allows for the loan of special equipment to those babies nursed at home, including a special cot with hot water bottles and blankets, draughtproof screens, a special feeding bottle and baby weighing scales. Arrangements were made with the Resident Medical Officer at Perivale Maternity Hospital by which the midwives could call her in consultation if necessary. For those babies who would be better transferred to hospital a special Oxygenaire cot was provided so that they may be given oxygen and kept warm during transit. All the Council's midwives attended a special course of a month's duration at the Post Graduate Hospital, Hammersmith. During 1950 86 premature babies were born in Ealing. Of these 14 were delivered in their own homes. The special equipment available was freely used, not only by those delivered at home, but also by those born in hospital and discharged home for special care when home facilities were adequate. Two cases were visited by the Resident Medical Officer at Perivale Maternity Hospital. All but two of the premature babies born at home survived the first month of life. These two babies were both extremely small. One baby weighed 1 lb. 12 ozs. and was transferred to Perivale Maternity Hospital in the special Oxygenaire tent but lived only 48 hours. The other baby weighed only 1 lb. 6 ozs. and lived 2 hours. Of the 146 premature babies born to mothers resident in Ealing, 20 died before the end of the first month of life, a mortality rate of 13.7% compared with 20.3% for the country as a whole for 1949. Ante-Natal Exercise and Mothercraft Classes in Ealing. Of recent years there has been a change in the attitude to the suffering of women in childbirth. In the past pain has been ANTE-NATAL, EXERCISES CLASS ANTE-NATAL, EXERCISES CLASS 65 considered the inevitable accompaniment of a perfectly natural phenomenon, only to be relieved by "twilight sleep," gas and air analgesia or full anaesthesia. Over the past few years it has become recognised that in normal cases the underlying cause of most women's suffering is fear—fear of the unknown, and as occurs throughout the animal kingdom, the response of the human body to fear is tension, or the simultaneous contraction of all muscles. The result of such tension is not only to delay the passage of the baby through the birth canal, but also to exhaust the woman through prolonged and unproductive physical effort. With the aim and object of overcoming this state of tension, the clinics in Ealing have for the past eighteen months held classes for women expecting their first babies. At these classes the women are taught how to achieve complete relaxation at will. They also perform to music certain exercises which have been evolved to develop those muscles which will be used to bring the baby into the world. The mothers are also given talks on diet, hygiene and clothing during pregnancy, the care of a young infant, and also the three stages of labour are explained with the aid of diagrams. There are at present three "exercise" classes held each week in the Borough, two at the Mattock Lane Clinic and one at the Cherington House Clinic, and it is expected that one will start at Ravenor Park Clinic as soon as a proposed extension to the premises is completed. The expectant mother attends for one session each week from the third or fourth month of pregnancy onwards until the time she goes into labour, and she is advised to perform the exercises and to practice relaxation at home daily. Over 100 expectant mothers who have attended the class have now been confined and many letters of appreciation have been received from them. Talks on mothercraft are also given to expectant mothers at other clinics where through lack of room or equipment, there is no exercise class. During the last two months of pregnancy every expectant mother is given instruction in the technique of breast massage. She is asked to practice this daily to express the colostrum, which is a fluid formed in the breasts towards the end of pregnancy and before the milk comes in on the second-third day after delivery. This practice has for long been in operation at the Mothers' and Babies' Hospital, Woolwich. Noting the very excellent results as regards breast feeding that they claim to have obtained there, we invited Dr. Waller, paediatrician to the hospital, to address 66 our medical and nursing staff in March, 1950. Since then we have been carrying out his teaching, the rationale of which is, that by the expression of this fluid, the milk ducts are opened up, creating a free passage for the flow of milk later. This avoids the condition of breast tension, which is not only uncomfortable and sometimes extremely painful for the mother, but may also by pressure on the milk forming part of the breast tissue, cause a complete cession of milk formation by the second or third week after delivery. At present we have not enough figures available to show statistically the value of this teaching, but the general impression gained by the mid wives and health visitors has been very favourable. Those expectant mothers who are to be confined in Perivale Maternity Hospital are, by permission of the Matron, allowed to visit the hospital in order that they may be acquainted with the premises and the staff. These expectant mothers are enabled therefore to approach their confinement in confidence and with a full understanding of what lies ahead. Mothercraft Teaching of School Girls in Day Nurseries. For many years now the day nurseries, seven in number, within the Borough of Ealing (administered by the County Council as Local Health Authority since July, 1948) have been recognised for the training of nursery nurses. It was felt, however, that in these nurseries there is a wealth of practical material which could be put to a wider use. In the summer of 1948 I suggested to the Chief Education Officer that the teaching of mothercraft to the elder girls in the secondary modern schools should be included as part of the curriculum, and that both the theoretical and practical training could be given on day nursery premises. Classes were accordingly started at four of the nurseries—at Cuckoo nursery for Costons School, at Stanhope nursery for Wood End School, at Culmington Road nursery for Northfields School, and at Perivale nursery for Perivale School. Each class, consisting of 20-25 girls between 14 and 15 years of age, attends at the nursery for one hour a week for six weeks. They are given simple talks on diet and the value of breast feeding is stressed. They are also given practical demonstration on making up a baby's bottle of cow's milk and of dried milk, and are shown how to cleanse the bottles and teats afterwards. Practical demonstrations are also given on bathing a baby and a toddler ; on hair washing, on how to make up a baby's cot and pram, and valuable hints are given to them in the making of improvised toys. About 1,400 girls have already attended these classes. Reproduced from " Our Changing Schools " by permission of the Controller of H.M. Stationery Office. 67 It is difficult to assess at the moment the value of the instruction given, but I feel confident that these adolescent girls, the potential mothers of the next generation, will show in full measure a justification and a return for the efforts made by raising even further the high standard of mothercraft in this Borough. My only regret is that practical teaching of this kind, which is so desirable to every young girl, is only able to be carried out to such a limited extent in State schools. Day nurseries are an expensive public service, but by this scheme they are enabled to make some return for their cost by giving an educational service to the older girls. One positive result of the scheme which we have observed is that several girls who have attended these classes have been inspired to take up nursery nursing as a career and a number have decided to make sick nursing their ultimate ambition. WELL WOMAN CLINICS The problems of the menopause were raised by me as a public health matter at the Area Health Committee at the beginning of the year. It was felt that there was a need for clinics for those women who were finding difficulties with the physiological alterations that so often occur at this period. After consultation with the Chairman of the Area Health Committee, who had seen similar clinics in operation in Canada, I approached the Hospital Management Committees working in the Ealing area and the Middlesex Local Medical Committee. The Local Medical Committee unfortunately took the view that this would encroach on the province of the general practitioners and they were not therefore prepared to recommend such arrangements to the medical profession. Under these circumstances no further progress was possible. HOME HELP SERVICE Although the Home Help Service has been in operation to a limited extent since 1919, when domestic assistance was provided for mothers during home confinements only, and was extended in 1945 when 40 Home Helps were employed to give assistance in certain cases of illness, it has increased enormously since the National Health Service Act came into operation in July, 1948, and can now be considered a most important part of our social service. One hundred and fifty Home Helps were employed in Ealing during 1950, some in a whole time and some in a part-time capacity. The service is supervised by the Home Help Organiser and three Assistant Organisers, whose duty it is to visit the cases before help is given, to allocate the Home Helps, and to make subsequent visits to ensure that help is still needed and is satisfactory. 68 Applications for help are received from various sources, from hospitals, general practitioners' clinics, the Haling Chest Clinic, the British Red Cross, W.V.S., etc. First priority is given to maternity cases where the confinement takes place at home. The Home Help for such a case is booked in advance and attends full-time (9—5) for 14 days. Cases of tuberculosis are given next consideration on the recommendation of the Chest Physician. No permanent help can be guaranteed for cases of acute illness or for the chronic sick, as the scheme provides for emergencies only, but help is allocated as far as the establishment permits. The duties of the Home Help include cooking, cleansing, shopping, looking after the children and the washing of such articles as are usually done at home. A special "squad" exists to deal with households that have got into such a dirty state that one Home Help would have difficulty in getting the premises clean, and the department has available a stock of cleansing material for such homes. During the year the question of Tuberculosis developing in Home Helps who had been working in the homes of persons suffering from Tuberculosis was raised at the Area Health Committee. This arose from cases which had occurred in Ealing, and as a result of the representations made, the Government extended the Insurance provisions to cover this type of case, in addition to the cases where nurses may have contracted Tuberculosis from patients. This will ensure that justice is done in cases where there is little doubt that an infectious background has been present during the working period of the Home Help and Tuberculosis is developed at a later stage. The Home Help service is not a free service and charges are made based on the number of hours help given to each case. Any person who is unable to bear the full cost may apply for the charges to be assessed according to the family financial circumstances. During 1950 help was provided for a total of 975 cases, of these 175 were maternity cases, 52 were cases of tuberculosis and 750 were cases of illness and senility. In addition, a further 149 cases who were receiving help in January, 1950, were still receiving help on December 31st, 1950. The Home Help Service works in close liaison with other organisations whose concern is the welfare of the sick and aged. The British Red Cross Society supply sick room equipment and will also arrange transport to and from hospital. The Society also supplies a "Meals on Wheels" service for providing hot meals for the aged 69 and bedridden for a small charge. The W.V.S. help with the supply of clothing and the Central Aid Society will supply bedding, clothing, kitchen equipment and curtaining to worthy cases. A number of elderly folk enjoyed a holiday at Bexhill arranged at a reduced rate by the Old People's Welfare Committee. The Ealing Council have always taken a great interest in the care of Old People in its boundary and grants have been made to voluntary bodies who have schemes working to this end. In addition, the British Red Cross Society have special facilities for the care of the aged. Photographs in this report show the buildings that are principally dealing with the residential facilities for the old people. THE CARE OF THE ELDERLY (The "elderly" covering all those persons coming into the Old Age Pension age-groups). It is common knowedge that the proportion of the population in this group has been changing for some years, and the position can be shown thus: ??? population ??? aged. In actual figures, it can be said that in 1900 there were 1½ million, in 1946 there were 6½ million, and in 1951 there will be 9½ million old people. Another aspect of this increasing expectation of life is that whereas in 1891 some 18% reached the age of 75 years, in 1945 the proportion rose to 43%. The need for hospital beds for the elderly has been estimated at 1½ to 2 beds for 1,000 population (for Ealing, 360 beds). The commonest complaints of the elderly are: Rheumatism 55%; Bronchitis 40%; Pain in the feet 40%; Frequency or difficulty in passing water 30%. Three out of four women over 85 have giddy spells, 4% of elderly at home are mentally abnormal, and 15% of elderly at home have slight mental aberrations. 70 The number of elderly persons in Ealing is estimated at approximately 17,000. An analysis of the records of the Ealing Home Nursing Service shows that over 50% of the cases come into the elderly group, whilst the Ealing. Home Help Service figures show almost 60% of its cases in this group. Approximately 40 new cases each week are under the care of Home Nurses. At present 200 cases are having Home Helps weekly. There is one Old Persons Home at 22, Park Hill, Ealing, which is controlled by the Middlesex County Council, and this provides accommodation for 3 males and 21 females. The County Council also intend at some date in the future to open a Home at 86 Mattock Lane, Ealing, which will cater for 25 persons and a Home at 3, Woodfield Road, which will deal with 19 persons. There is an Eventide Home in Castlebar Road which is under the control of Ealing Eventide Homes Ltd., and an extension is under consideration. The British Red Cross Society have a Home for the Aged in Mount Park Road which provides for 24 persons. The King Edward Hospital Fund for London intend opening a Home for Old People at "Greenfield," Courtfield Gardens, and the Home will be conducted by the British Red Cross Society. It is expected that this will provide accommodation for 30 persons. There are 8 private Homes for the Aged in the Borough and these provide accommodation for approximately 9 males and 79 females. The Nursing Homes in Ealing (including Maternity Homes) accommodate 220 patients in all and of these about 100 are at present elderly persons. A "Meals on Wheels" Service is provided by the local British Red Cross Society and they issue approximately 8,400 meals per annum. A charge of 1/- per meal is made and the whole of the Borough is served. There is usually a choice of main meal and special diets are catered for. The Council make a grant of £720 per annum towards the cost of this service. The Council have under consideration the granting of aid to voluntary bodies who arrange for holiday homes for old people. In the appendix a list is given of the organisations who help old persons in various ways. A large field of social service for the elderly remains to be explored. Much valuable work is being done by voluntary bodies on lines analogous to that done by similar bodies in the early exploratory work into Maternity and Child Welfare problems. OLD PEOPLES HOME, "DOWNHURST," CASTLEBAR ROAD, EALING. (EALING EVENTIDE HOMES LTD). OLD PERSONS HOME, " SOUTHFIELD," MOUNT PARK ROAD (BRITISH RED CROSS SOCIETY, EASING) OLD PERSONS HOME, 36, WARWICK ROAD (EALING HOUSING ASSOCIATION) OLD PERSONS HOME, PARK HILL (MIDDLESEX COUNTY COUNCIL) MIDWIFE HEALTH VISITOR HOME NURSE HOME HELP 71 Voluntary Organisations in the Borough who assist Old People in Various Ways. British Red Cross Society. Women's Voluntary Service. Haling Council of Social Service. Ealing Central Aid Society. Ealing Eventide Homes Ltd. Ealing Philanthropic Institutions. Greenford Philanthropic Society. Hanwell Veterans Club. Northolt Veterans Club. UNIFORMS. In view of the changes in uniform of a number of health service staff since the County Council took over many of the Borough Council's services, it was felt that the photographs opposite would be of public interest. Health Visitors wear navy blue costumes, hat or beret, and greatcoat, with a white or blue blouse. A badge is to be supplied. Uniform for health visitors is a departure from the pre-1948 Ealing policy when they wore mufti. Midwives, who used to wear green, now have the national midwives uniform, which consists of grey greatcoat and hat or beret piped with cornflower blue. The hat has a badge of silver wire on cornflower ground. Dresses are blue gingham with white collar and cuffs. Home Nurses wear the State Registered Nurses Uniform or the "Queen's " uniform. State Registered Nurses uniform is navy coat and hat with silver wire initials on epaulettes. There is a choice of four hats each with a cockade and silver wire badge. The Home Nurse in the photograph is wearing a "Wingate" hat. The other hats are peaked cap, beret or the "Marlborough." The Home Help staff are issued with two coat overalls, either blue or green coloured, at the commencement of service, and an extra one in special cases. The overalls are only on loan and are returned at the termination of service. 72 HOUSING PROGRESS The basic factors in the maintenance of health are good housing, good food and a happy family life. The house has been defined as a "machine for living in." Like all machines, it has a finite life and requires frequent repairs and renewals if it is not to become inefficient and out of date. Changing standards of modern life demand facilities and conveniences not thought of by our forefathers. The Housing Advisory Committee report of 1946 laid down these standards for a satisfactory house : 1. In all respects dry. 2. In a good State of repair. 3. Each room properly lighted and ventilated. 4. Have an adequate supply of wholesome water laid on for all purposes inside the dwelling. 5. Provided with efficient and adequate means of supplying hot water. 6. Have an internal or otherwise readily accessible water-closet. 7. Have a fixed bath, preferably in a separate room. 8. Be provided with a sink or sinks and with suitable ments for the disposal of waste water. 9. Be provided with facilities for domestic washing, including a copper, preferably in a separate room. 10. Have a proper drainage system. 11. Be provided with adequate points for artificial lighting in each room. 12. Be provided with adequate facilities for heating each able room. 13. Have satisfactory facilities for preparing and cooking food. 14. Have a well ventilated larder or food store. 15. Have a proper provision for the storage of fuel. 16. Have a satisfactory surfaced path to outbuildings and convenient access from street to the back door. Unhappily, the housing shortage remains severe in spite of all efforts, as is evidenced by the long waiting lists. The amount of friction and unhappiness produced by overcrowding is immeasurable, whilst the direct relationship between overcrowding and spread of infectious disease (such as Tuberculosis) has been amply proved. COUNCIL HOUSES AT NORTHOLT OLD PEOPLE'S BUNGALOWS AT NORTHOLT 73 The Council has laid down by a "points scheme" which takes into account various factors, including special needs on medical grounds. Houses are therefore allocated on the basis of need. Rising costs of building and defence needs threaten to reduce the number of houses available, but every effort is being made to maintain the flow. We are between "Scylla and Charybdis" insofar as repeated economy demands are tending to reduce standards below normal limits of comfort; and rising costs threaten to put the economical rents outside the range of the persons for whom they are intended. A notable feature this year has been the provision of 12 old people's dwellings on the South East Northolt Estate i.e., about 3% of the total completed). Too often one finds elderly people living under the most unsuitable circumstances and often in large old houses with far too many rooms for their present needs, yet unable to move because of economic factors. It is obviously sound policy in these cases to offer new homes to these people and thus free the larger houses for growing families. The present policy is to generally encourage exchanges of houses and flats to make the best use of existing accommodation. The elderly require homes that are small, warm, on the level and with few stairs. Such conveniences as an indoor fuel store and W.C. are essential for those who are becoming enfeebled. The old person likes to feel in touch with the rest of the community so that these dwellings have been made part of a larger estate where they are within reasonable distance of bus services, post offices, churches and cinemas. With the increasing number of elderly folk the need for this accommodation is increasing, and we may venture to hope that future schemes will include a substantially greater number of such dwellings. Ealing has a proud record in the field of housing. During the year 378 permanent houses and flats were completed, thus making a total of 1,539 since the end of the war. In addition, 645 temporary dwellings have been built and 552 premises have been requisitioned. These efforts have not been equalled in any other area of Middlesex. Perry & Routleff Ltd., Printers, Ealing and Uxbridge